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Objective: Identify trends of navigation and robotic-assisted elective spine surgeries. Methods: Elective spine surgery patients between 2007 and 2015 in the Nationwide Inpatient Sample (NIS) were isolated by ICD-9 codes for Navigation [Nav] or Robotic [Rob]-Assisted surgery. Basic demographics and surgical variables were identified via chi-squared and t tests. Each system was analyzed from 2007 to 2015 for trends in usage. Results: Included 3,759,751 patients: 100,488 Nav; 4724 Rob. Nav were younger (56.7 vs 62.7 years), had lower comorbidity index (1.8 vs 6.2, all p < 0.05), more decompressions (79.5 vs 42.6%) and more fusions (60.3 vs 52.6%) than Rob. From 2007 to 2015, incidence of complication increased for Nav (from 5.8 to 21.7%) and Rob (from 3.3 to 18.4%) as well as 2–3 level fusions (from 50.4 to 52.5%) and (from 1.3 to 3.2%); respectively. Invasiveness increased for both (Rob: from 1.7 to 2.2; Nav: from 3.7 to 4.6). Posterior approaches (from 27.4 to 41.3%), osteotomies (from 4 to 7%), and fusions (from 40.9 to 54.2%) increased in Rob. Anterior approach for Rob decreased from 14.9 to 14.4%. Nav increased posterior (from 51.5% to 63.9%) and anterior approaches (from 16.4 to 19.2%) with an increase in osteotomies (from 2.1 to 2.7%) and decreased decompressions (from 73.6 to 63.2%). Conclusions: From 2007 to 2015, robotic and navigation systems have been performed on increasingly invasive spine procedures. Robotic systems have shifted from anterior to posterior approaches, whereas navigation computer-assisted procedures have decreased in rates of usage for decompression procedures. [ABSTRACT FROM AUTHOR]

Background: Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods: This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004–2011. Chiari malformation Types 1–4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results: One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40–50 years had the most reoperations (11); however, patients aged 15–20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions: Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes. [ABSTRACT FROM AUTHOR]

Background: Three-column osteotomies (3COs), usually in the form of pedicle subtraction or vertebral column resection, have become common in adult spinal deformity surgery. Although a powerful tool for deformity correction, 3COs can increase the risks of perioperative morbidity.Methods: Operative patients with adult spinal deformity (Cobb angle of >20°, sagittal vertical axis [SVA] of >5 cm, pelvic tilt of >25°, and/or thoracic kyphosis of >60°) with available baseline and 2-year radiographic and health-related quality-of-life (HRQoL) data were included. Patients were stratified into 2 groups by surgical year: Group I (2008 to 2013) and Group II (2014 to 2018). Patients with 3COs were then isolated for outcomes analysis. Severe sagittal deformity was defined by an SVA of >9.5 cm. Best clinical outcome (BCO) was defined as an Oswestry Disability Index (ODI) of <15 and Scoliosis Research Society (SRS)-22 of >4.5. Multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical parameters.Results: Seven hundred and fifty-two patients with adult spinal deformity met the inclusion criteria, and 138 patients underwent a 3CO. Controlling for baseline SVA, PI-LL (pelvic incidence minus lumbar lordosis), revision status, age, and Charlson Comorbidity Index (CCI), Group II was less likely than Group I to have a 3CO (21% versus 31%; odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.97) and more likely to have an anterior lumbar interbody fusion (ALIF; OR = 1.6; 95% CI = 1.3 to 2.3) and a lateral lumbar interbody fusion (LLIF; OR = 3.8; 95% CI = 2.3 to 6.2). Adjusted analyses showed that Group II had a higher likelihood of supplemental rod usage (OR = 21.8; 95% CI = 7.8 to 61) and a lower likelihood of proximal junctional failure (PJF; OR = 0.23; 95% CI = 0.07 to 0.76) and overall hardware complications by 2 years (OR = 0.28; 95% CI = 0.1 to 0.8). In an adjusted analysis, Group II had a higher likelihood of titanium rod usage (OR = 2.7; 95% CI = 1.03 to 7.2). Group II had a lower 2-year ODI and higher scores on Short Form (SF)-36 components and SRS-22 total (p < 0.05 for all). Controlling for baseline ODI, Group II was more likely to reach the BCO for the ODI (OR = 2.8; 95% CI = 1.2 to 6.4) and the SRS-22 total score (OR = 4.6; 95% CI = 1.3 to 16).Conclusions: Over a 10-year period, the rates of 3CO usage declined, including in cases of severe deformity, with an increase in the usage of PJF prophylaxis. A better understanding of the utility of 3CO, along with a greater implementation of preventive measures, has led to a decrease in complications and PJF and a significant improvement in patient-reported outcome measures.Level Of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: To investigate normal curvature ratios of the cervicothoracic spine and to establish radiographic thresholds for severe myelopathy and disability, within the context of shape. Methods: Adult cervical deformity (CD) patients undergoing cervical fusion were included. C2-C7 Cobb angle (CL) and thoracic kyphosis (TK), using T2-T12 Cobb angle, were used as a ratio, ranging from −1 to + 1. Pearson bivariate r and univariate analyses analyzed radiographic correlations and differences in myelopathy(mJOA > 14) or disability(NDI > 40) across ratio groups. Results: Sixty-three CD patients included. Regarding CL:TK ratio, 37 patients had a negative ratio and 26 patients had a positive ratio. A more positive CL:TK correlated with increased TS-CL(r = 0.655, p = < 0.001)and mJOA(r = 0.530, p = 0.001), but did not correlate with cSVA/SVA or NDI scores. A positive CL:TK ratio was associated with moderate disability(NDI > 40)(OR: 7.97[1.22–52.1], p = 0.030). Regression controlling for CL:TK ratio revealed cSVA > 25 mm increased the odds of moderate to severe myelopathy and cSVA > 30 mm increased the odds of significant neck disability. Lastly, TS-CL > 29 degrees increased the odds of neck disability by 4.1 × with no cutoffs for severe mJOA(p > 0.05). Conclusions: Cervical deformity patients with an increased CL:TK ratio had higher rates of moderate neck disability at baseline, while patients with a negative ratio had higher rates of moderate myelopathy clinically. Specific thresholds for cSVA and TS-CL predicted severe myelopathy or neck disability scores, regardless of baseline neck shape. A thorough evaluation of the cervical spine should include exploration of relationships with the thoracic spine and may better allow spine surgeons to characterize shapes and curves in cervical deformity patients. [ABSTRACT FROM AUTHOR]

Background Adolescent idiopathic scoliosis (AIS) is the most common form of abnormal spine curvature observed in patients age 10 to 18. Typically characterized by shoulder height and waistline asymmetry, AIS may drive uneven distribution of force in the hips, leading to increased rates of concurrent hip diagnoses. The relationship between AIS and concurrent hip diagnoses is underexplored in the literature, and to date, there has been little research comparing rates of hip diagnoses between patients with AIS and those unaffected. Purpose Assess differences in rates and clusters of hip diagnoses between patients with AIS and those unaffected. Study design Retrospective review of Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS). Patient sample 224,504 weighted inpatient discharges. Outcome measures Rates of hip diagnoses. Methods Patients in the NIS database (2005-2013) ages 10-18 years were isolated. Patients were grouped by those diagnosed with AIS (ICD-9: 737.30) and those unaffected. Patient groups were propensity score matched (PSM) for age. Means comparison tests assessed differences in demographic, comorbidity, and diagnosis profiles between patient groups for corresponding age categories. ICD-9 codes were used to identify specific hip diagnoses. Results Following PSM, 24,656 AIS and 24,656 unaffected patients were included. The AIS patient group was comprised of more females (66% vs 59%) and had lower rates of obesity (2.4% vs 3.5%, both p < 0.001). Overall, 1.1% of patients had at least one hip diagnosis: congenital deformity (0.31%), developmental dysplasia (0.24%), recurrent dislocation (0.18%), isolated dislocation (0.09%), osteonecrosis (0.08%), osteochondrosis (0.07%), acquired deformity (0.03%), and osteoarthritis (0.02%). AIS patients had lower rates of osteonecrosis (0.04% vs 0.12%, p = 0.003), but higher rates of all other hip diagnoses, including dysplasia (0.41% vs 0.07%, p < 0.001), recurrent dislocation (0.32% vs 0.03%, p < 0.001), isolated dislocation (0.13% vs 0.06%, p < 0.001), and osteoarthritis (0.04% vs 0.01%, p = 0.084. Co- occurrences of hip diagnoses were relatively rare, with 0.03% patients having more than one hip diagnosis. Rates of co-occurring hip diagnoses did not differ between AIS and unaffected groups (0.04% vs 0.02%, p = 0.225). Conclusions Compared to unaffected patients of similar ages, patients with AIS had higher overall rates of hip diagnoses, including dysplasia and recurrent dislocation. A higher trend of precocious osteoarthritis was also observed at a higher rate in AIS patients, although this difference was not statistically significant. Our results present an argument for surgical realignment in the coronal and sagittal planes to neutralize asymmetrical forces in the hips, and suggest the need for increased awareness and clinical screening for hip-related disorders in AIS patients. Level of Evidence III. [ABSTRACT FROM AUTHOR]

Purpose: To determine the validity and responsiveness of PROMIS metrics versus the SRS-22r questionnaire in adult spinal deformity (ASD). Methods: Surgical ASD patients undergoing ≥ 4 levels fused with complete baseline PROMIS and SRS-22r data were included. Internal consistency (Cronbach's alpha) and test–retest reliability [intraclass correlation coefficient (ICC)] were compared. Cronbach's alpha and ICC values ≥ 0.70 were predefined as satisfactory. Convergent validity was evaluated via Spearman's correlations. Responsiveness was assessed via paired samples t tests with Cohen's d to assess measure of effect (baseline to 3 months). Results: One hundred and ten pts are included. Mean baseline SRS-22r score was 2.62 ± 0.67 (domains = Function: 2.6, Pain: 2.5, Self-image: 2.2, Mental Health: 3.0). Mean PROMIS domains = Physical Function (PF): 12.4, Pain Intensity (PI): 91.7, Pain Interference (Int): 55.9. Cronbach's alpha, and ICC were not satisfactory for any SRS-22 and PROMIS domains. PROMIS-Int reliability was low for all SRS-22 domains (0.037–0.225). Convergent validity demonstrated strong correlation via Spearman's rho between PROMIS-PI and overall SRS-22r (− 0.61), SRS-22 Function (− 0.781), and SRS-22 Pain (− 0.735). PROMIS-PF had strong correlation with SRS-22 Function (0.643), while PROMIS-Int had moderate correlation with SRS-22 Pain (− 0.507). Effect size via Cohen's d showed that PROMIS had superior responsiveness across all domains except for self-image. Conclusions: PROMIS is a valid measure compared to SRS-22r in terms of convergent validity, and has greater measure of effect in terms of responsiveness, but failed in reliability and internal consistency. Surgeons should consider the lack of reliability and internal consistency (despite validity and responsiveness) of the PROMIS to SRS-22r before replacing the traditional questionnaire with the computer-adaptive testing. [ABSTRACT FROM AUTHOR]

Hypothesis: The myelopathy-based cervical deformity (CD) thresholds will associate with patient-reported outcomes and complications. Materials and Methods: This study include CD patients (C2-C7 Cobb > 10°, CL > 10°, cervical sagittal vertical axis > 4 cm, or CBVA > 25°) with BL and 1-year (1Y) data. Modifiers assessed low (L), moderate (M), and severe (S) deformity: CL (L: >3°; M:-21° to 3°; S: <‒21°), TS-CL (L: <26°; M: 26° to 45°; S: >45°), C2-T3 angle (L: >‒25°; M:-35° to-25°; S: <‒35°), C2 slope (L: <33°; M: 33° to 49°; S: >49°), MGS (L: >‒9° and < 0°; M: ‒12° to ‒9° or 0° to 19°; S: < ‒12° or > 19°), and frailty (L: <0.18; M: 0.18–0.27, S: >0.27). Means comparison and ANOVA assessed outcomes in the severity groups at BL at 1Y. Correlations found between modifiers assessed the internal relationship. Results: One hundred and four patients were included in the study (57.1 years, 50%, 29.3 kg/m2). Baseline S TS-CL, C2-T3, and C2S modifiers were associated with increased reoperations (P < 0.01), while S MGS, CL, and C2-T3 had increased estimated blood lost (>1000ccs, P < 0.001). S MGS and C2-T3 had more postop DJK (60%, P = 0.018). Improvement in TS-CL, C2S, C2-T3, and CL patients had better numeric rating scale (NRS) back (<5) and EuroQOL 5-Dimension questionnaire (EQ5D) at 1 year (P < 0.05). Improving the modifiers correlated strongly with each other (0.213–0.785, P < 0.001). Worsened TS-CL had increased NRS back scores at 1 year (9, P = 0.042). Worsened CL had increased 1-year modified Japanese Orthopedic Association (mJOA) (7, P = 0.001). Worsened C2-T3 had worse NRS neck scores at 1 year (P = 0.048). Improvement in all six modifiers (8.7%) had significantly better health-related quality of life (HRQL) scores at follow-up (EQ5D, NRS, and Neck Disability Index). Conclusions: Newly proposed CD modifiers based on mJOA were closely associated with outcomes. Improvement and deterioration in the modifiers significantly impacted the HRQL. [ABSTRACT FROM AUTHOR]

Background: Recent studies have evaluated the correlation of health-related quality of life (HRQL) scores with radiographic parameters. This relationship may provide insight into the connection of patient-reported disability and disease burden caused by cervical diagnoses. Purpose: To evaluate the association between spinopelvic sagittal parameters and HRQLs in patients with primary cervical diagnoses. Methods: Patients ≥18 years meeting criteria for primary cervical diagnoses. Cervical radiographic parameters assessed cervical sagittal vertical axis, TS-CL, chin-to-brow vertical angle, C2-T3, CL, C2 Slope, McGregor's slope. Global radiographic alignment parameters assessed PT, SVA, PI-LL, T1 Slope. Pearson correlations were run for all combinations at baseline (BL) and 1 year (1Y) for continuous BL and 1Y modified Japanese Orthopaedic Association scale (mJOA) scores, as well as decline or improvement in those HRQLs at 1Y. Multiple linear regression models were constructed to investigate BL and 1Y alignment parameters as independent variables. Results: Ninety patients included 55.6 ± 9.6 years, 52% female, 30.7 ± 7kg/m2. By approach, 14.3% of patients underwent procedures by anterior approach, 56% posterior, and 30% had combined approaches. Average anterior levels fused: 3.6, posterior: 4.8, and mean total number of levels fused: 4.5. Mean operative time for the cohort was 902.5 minutes with an average estimated blood loss of 830 ccs. The mean BL neck disability index (NDI) score was 56.5 and a mJOA of 12.81. While BL NDI score correlated with gender (P = 0.050), it did not correlate with BL global or cervical radiographic factors. An increased NDI score at 1Y postoperatively correlated with BL body mass index (P = 0.026). A decreased NDI score was associated with 1Y T12-S1 angle (P = 0.009) and 1Y T10 L2 angle (P = 0.013). Overall, BL mJOA score correlated with the BL radiographic factors of T1 slope (P = 0.005), cervical lordosis (P = 0.001), C2-T3 (P = 0.008), C2 sacral slope (P = 0.050), SVA (P = 0.010), and CL Apex (P = 0.043), as well as gender (P = 0.050). Linear regression modeling for the prior independent variables found a significance of P = 0.046 and an R2 of 0.367. Year 1 mJOA scores correlated with 1Y values for maximum kyphosis (P = 0.043) and TS-CL (P = 0.010). At 1Y, a smaller mJOA score correlated with BL S1 sacral slope (P = 0.014), pelvic incidence (P = 0.009), L1-S1 (P = 0.012), T12-S1 (P = 0.008). The linear regression model for those 4 variables demonstrated an R2 of 0.169 and a P = 0.005. An increased mJOA score correlated with PI-LL difference at 1Y (P = 0.012), L1-S1 difference (P = 0.036), T12-S1 difference (0.006), maximum lordosis (P = 0.026), T9-PA difference (P = 0.010), and difference of T4-PA (P = 0.008). Conclusions: While the impact of preoperative sagittal and cervical parameters on mJOA was strong, the BL radiographic factors did not impact NDI scores. PostOp HRQL was significantly associated with sagittal parameters for mJOA (both worsening and improvement) and NDI scores (improvement). When cervical surgery has been indicated, radiographic alignment is important for postoperative HRQL. [ABSTRACT FROM AUTHOR]

Objective: To prioritize the cervical parameter targets for alignment. Methods: Included: cervical deformity (CD) patients (C2–7 Cobb angle > 10°, cervical lordosis > 10°, cervical sagittal vertical axis [cSVA] > 4 cm, or chin-brow vertical angle > 25°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical [C] or cervicothoracic [CT] Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA ( < 4 cm) and T1 slope minus cervical lordosis (TS–CL) ( < 15°) were excluded. Patients assessed: meeting minimum clinically important differences (MCID) for NDI ( < -15 ΔNDI). Ratios of correction were found for regional parameters categorized by primary Ames driver (C or CT). Decision tree analysis assessed cutoffs for differences associated with meeting NDI MCID at 1Y. Results: Seventy-seven CD patients (mean age, 62.1 years; 64% female; body mass index, 28.8 kg/m²). Forty-one point six percent of patients met MCID for NDI. A backwards linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R² of 0.820 (p = 0.032) included TS–CL, cSVA, McGregor’s slope (MGS), C2 sacral slope, C2–T3 angle, C2–T3 SVA, cervical lordosis. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the 2 groups (p > 0.050). Decision tree analysis determined cutoffs for radiographic change, prioritizing in the following order: ≥ 42.5° C2–T3 angle, > 35.4° cervical lordosis, < -31.76° C2 slope, < -11.57-mm cSVA, < -2.16° MGS, > -30.8-mm C2–T3 SVA, and ≤ -33.6° TS–CL. Conclusion: Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient- reported outcomes for patients undergoing CD surgery. [ABSTRACT FROM AUTHOR]

Objective: Malalignment of the cervical spine can result in cord compression, leading to a myelopathy diagnosis. Whether deformity or myelopathy severity is stronger predictors of surgical outcomes is understudied. Methods: Surgical cervical deformity (CD) patients with baseline (BL) and up to 1-year data were included. Modified Japanese Orthopaedic Association (mJOA) score categorized BL myelopathy (mJOA = 18 excluded), with moderate myelopathy mJOA being 12 to 17 and severe myelopathy being less than 12. BL deformity severity was categorized using the mismatch between T1 slope and cervical lordosis (TS-CL), with CL being the angle between the lower endplates of C2 and C7. Moderate deformity was TS-CL less than or equal to 25° and severe deformity was greater than 25°. Categorizations were combined into 4 groups: group 1 (G1), severe myelopathy and severe deformity; group 2 (G2), severe myelopathy and moderate deformity; group 3 (G3), moderate myelopathy and moderate deformity; group 4 (G4), moderate myelopathy and severe deformity. Univariate analyses determined whether myelopathy or deformity had greater impact on outcomes. Results: One hundred twenty-eight CD patients were included (mean age, 56.5 years; 46% female; body mass index, 30.4 kg/m²) with a BL mJOA score of 12.8 ± 2.7 and mean TSCL of 25.9° ± 16.1°. G1 consisted of 11.1% of our CD population, with 21% in G2, 34.6% in G3, and 33.3% in G4. At BL, Neck Disability Index (NDI) was greatest in G2 (p = 0.011). G4 had the lowest EuroQol-5D (EQ-5D) (p < 0.001). Neurologic exam factors were greater in severe myelopathy (p < 0.050). At 1-year, severe deformity met minimum clinically important differences (MCIDs) for NDI more than moderate deformity (p = 0.002). G2 had significantly worse outcomes compared to G4 by 1-year NDI (p = 0.004), EQ-5D (p = 0.028), Numerical Rating Scale neck (p = 0.046), and MCID for NDI (p = 0.001). Conclusion: Addressing severe deformity had increased clinical weight in improving patient- reported outcomes compared to addressing severe myelopathy. [ABSTRACT FROM AUTHOR]

Background: The lower instrumented vertebrae (LIVs) in cervical deformity (CD) constructs may have varying effects on patient outcomes that are still poorly understood. Objective: The objective of the study is to compare outcomes in CD patients undergoing instrumented correction according to the relation of LIV with primary driver (PD). Methods: Patients who met radiographic criteria for CD were included in the study. Patients were stratified by PD of deformity: cervical (C) through AMES classification (TS-CL >20 or cervical sagittal vertical axis >40) and thoracic (T) through hyper/hypokyphosis (TK) from T4-T12 (60 < TK < 40). Patients were further stratified by LIV in relation to curve apex (above/below). Univariate and multivariate analyses identified group differences in postoperative health-related quality-of-life and distal junctional kyphosis (DJK) (>10° LIV and LIV + 2) rate up to 1 year. Results: Sixty-two patients were analyzed. Twenty-one patients had a C-PD and 41 had a T-PD by definition. 100% of C-PDs had LIVs below CL apex, while 9.2% of T-PDs had LIVs below (caudal) to TK apex and 90.8% had LIVs above TK apex. By 1 year, C patients trended lower Neck Disability Index (NDI) (21.9 vs. 29.0, P = 0.245), lower numeric rating scales neck pain (4.2 vs. 5.1, P = 0.358), and significantly higher EuroQol five-dimensional questionnaire Visual Analog Scale (69.2 vs. 52.4, P = 0.040). When T patients with LIVs below TK apex were excluded, remaining T patients with LIV above apex had significantly higher 1-year NDI than C patients (37.5 vs. 21.9, P = .05). T patients also trended higher rates of postoperative DJK than C (19.5% vs. 4.8%, P = 0.119). Conclusions: Stopping before apex was more common in patients with a primary thoracic driver (T) and associated with deleterious effects. Primary cervical driver (C) tended to have LIVs inclusive of CL apex with lower rates of DJK. [ABSTRACT FROM AUTHOR]

Introduction: Osteotomies are commonly performed to correct sagittal malalignment in cervical deformity (CD). However, the risks and benefits of performing a major osteotomy for cervical deformity correction have been understudied. The objective of this retrospective cohort study was to investigate the risks and benefits of performing a major osteotomy for CD correction. Methods: Patients stratified based on major osteotomy (MAJ) or minor (MIN). Independent t-tests and Chi-squared tests were used to assess differences between MAJ and MIN. A sub-analysis compared patients with flexible versus rigid CL. Results: 137 CD patients were included (62 years, 65% F). 19.0% CD patients underwent a MAJ osteotomy. After propensity score matching for cSVA, 52 patients were included. About 19.0% CD patients underwent a MAJ osteotomy. MAJ patients had more minor complications (P = 0.045), despite similar surgical outcomes as MIN. At 3M, MAJ and MIN patients had similar NDI, mJOA, and EQ5D scores, however by 1 year, MAJ patients reached MCID for NDI less than MIN patients (P = 0.003). MAJ patients with rigid deformities had higher rates of complications (79% vs. 29%, P = 0.056) and were less likely to show improvement in NDI at 1 year (0.95 vs. 0.54, P = 0.027). Both groups had similar sagittal realignment at 1 year (all P > 0.05). Conclusions: Cervical deformity patients who underwent a major osteotomy had similar clinical outcomes at 3-months but worse outcomes at 1-year as compared to minor osteotomies, likely due to differences in baseline deformity. Patients with rigid deformities who underwent a major osteotomy had higher complication rates and worse clinical improvement despite similar realignment at 1 year. [ABSTRACT FROM AUTHOR]

Background: Adolescent idiopathic scoliosis (AIS) is a common cause of spinal deformity in adolescents. AIS can be associated with certain intraspinal anomalies such as syringomyelia (SM). This study assessed the rate o f SM in AIS patients and compared trends in surgical approach and postoperative outcomes in AIS patients with and without SM. Methods: The database was queried using ICD-9 codes for AIS patients from 2003–2012 (737.1–3, 737.39, 737.8, 737.85, and 756.1) and SM (336.0). The patients were separated into two groups: AIS-SM and AIS-N. Groups were compared using t-tests and Chi-squared tests for categorical and discrete variables, respectively. Results: Totally 77,183 AIS patients were included in the study (15.2 years, 64% F): 821 (1.2%) – AIS-SM (13.7 years, 58% F) and 76,362 – AIS-N (15.2 years, 64% F). The incidence of SM increased from 2003–2012 (0.9 to 1.2%, P = 0.036). AIS-SM had higher comorbidity rates (79 vs. 56%, P < 0.001). Comorbidities were assessed between AIS-SM and AIS-N, demonstrating significantly more neurological and pulmonary in AIS-SM patients. 41.2% of the patients were operative, 48% of AIS-SM, compared to 41.6% AIS-N. AIS-SM had fewer surgeries with fusion (anterior or posterior) and interbody device placement. AIS-SM patients had lower invasiveness scores (2.72 vs. 3.02, P = 0.049) and less LOS (5.0 vs. 6.1 days, P = 0.001). AIS-SM patients underwent more routine discharges (92.7 vs. 90.9%). AIS-SM had more nervous system complications, including hemiplegia and paraplegia, brain compression, hydrocephalous and cerebrovascular complications, all P < 0.001. After controlling for respiratory, renal, cardiovascular, and musculoskeletal comorbidities, invasiveness score remained lower for AIS-SM patients (P < 0.001). Conclusions: These results indicate that patients concordant with AIS and SM may be treated more cautiously (lower invasiveness score and less fusions) than those without SM. [ABSTRACT FROM AUTHOR]