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Patients with less severe adult spinal deformity (ASD) undergo surgical correction and often achieve good clinical outcomes. However, it is not well understood how much clinical improvement is due to sagittal correction rather than treatment of the spondylotic process.Determine baseline thresholds in radiographic parameters that, when exceeded, may result in substantive clinical improvement from surgical correction.Retrospective.ASD patients with BL and two-year data were included. Parameters assessed: sagittal vertical axis, pelvic incidence-lumbar lordosis mismatch, pelvic tilt, T1 pelvic angle, L1 pelvic angle, L4-S1 lordosis, C2-C7 sagittal vertical axis, C2-T3, C2 slope. Outcomes: Good Outcome (GO) at two years: [meeting either: (1) Substantial Clinical Benefit for Oswestry Disability Index (change18.8), or (2) Oswestry Disability Index15 and Scoliosis Research Society Total4.5]. Binary logistic regression assessed each parameter to determine if correction was more likely needed to achieve GO. Conditional inference tree run machine learning analysis generated baseline thresholds for each parameter, above which, correction was necessary to achieve GO.We included 431 ASD patients. There were 223 (50%) that achieved a GO by two years. Binary logistic regression analysis demonstrated, with increasing baseline severity in deformity, sagittal correction was more often seen in those achieving GO for each parameter(all P0.001). Of patients with baseline T1 pelvic angle above the threshold, 95% required correction to meet GO (95% vs. 54%, P0.001). A baseline pelvic incidence-lumbar lordosis10° (74% of patients meeting GO) needed correction to achieve GO (odds ratio: 2.6, 95% confidence interval: 1.4-4.8). A baseline C2 slope15° also necessitated correction to obtain clinical success (odds ratio: 7.7, 95% confidence interval: 3.7-15.7).Our study highlighted point may be present at which sagittal correction has an outsized influence on clinical improvement, reflecting the line where deformity becomes a significant contributor to disability. These new thresholds give us insight into which patients may be more suitable for sagittal correction, as opposed to intervention for the spondylotic process only, leading to a more efficient utility of surgical intervention for ASD.

Retrospective cohort.The aim was to describe the two-year outcomes for patients undergoing surgical correction of cervical deformity (CD).Adult CD has been shown to compromise health-related quality of life. While advances in spinal realignment have shown promising short-term clinical results in this parameter, the long-term outcomes of CD corrective surgery remain unclear.Operative CD patients18 years with two-year (2Y) health-related quality of life/radiographic data were included. Improvement in radiographic, neurologic, and health-related quality of life outcomes were reported. Patients with a prior cervical fusion and patients with the greatest and smallest change based on Neck Disability Index (NDI), numeric rating scale (NRS) neck, modified Japanese Orthopaedic Association (mJOA) were compared using multivariable analysis controlling for age, and frailty, and invasiveness.One hundred and fifty-eight patients were included in this study. By 2Y, 96.3% of patients improved in Ames cervical sagittal vertical axis modifier, 34.2% in T1 slope minus cervical lordosis (TS-CL), 42.0% in horizontal gaze modifier, and 40.9% in SVA modifier. In addition, 65.5% of patients improved in Passias CL modifier, 53.3% in TS-CL modifier, 100% in C2-T3 modifier, 88.9% in C2S modifier, and 81.0% in MGS modifier severity by 2Y. The cohort significantly improved from baseline to 2Y in NDI, NRS Neck, and mJOA, all P0.05. 59.3% of patients met minimal clinically important difference for NDI, 62.3% for NRS Neck, and 37.3% for mJOA. Ninety-seven patients presented with at least one neurologic deficit at baseline and 63.9% no longer reported that deficit at follow-up. There were 45 (34.6%) cases of distal junctional kyphosis (DJK) (∆DJKA10° between lower instrumented vertebra and lower instrumented vertebra-2), of which 17 were distal junctional failure (distal junctional failure-DJK requiring reoperation). Patients with the greatest beneficial change were less likely to have had a complication in the two-year follow-up period.Correction of CD results in notable clinical and radiographic improvement with most patients achieving favorable outcomes after two years. However, complications including DJK or failure remain prevalent.

Retrospective single-center, consecutively enrolled database of adult spinal deformity (ASD) patients.The aim of this study was to assess the performance of the mASD-FI in predicting clinical and patient-reported outcomes after ASD-corrective surgery.The recently described modified Adult Spinal Deformity frailty index (mASD-FI) quantifies frailty of ASD patients, but the utility of this clinical prediction tool as a means of prognosticating postoperative outcomes has not been investigated.ASD patients with available mASD-FI scores and HRQL data at presentation and 2-years postop were included.Patients were stratified by mASD-FI score using published cutoffs: not frail (NF7), frail (F, 7-12), severely frail (SF,12). Analysis of vaiance assessed differences in patient factors across frailty groups. Linear regression assessed the relationship of mASD-FI with length of stay (LOS) and HRQLs. Multivariable logistic regression revealed how frailty category predicted odds of complications, infections and reoperation.A total of 509 patients included (59 years, 79%F, 27.7 kg/m 2 ). The cohort presented with moderate baseline deformity: sagittal vertical axis (83.7 mm ± 71), PT (12.7° ± 10.8°), PI-LL (43.1° ± 21.1°). Mean preoperative mASD-FI score was 7.2, frailty category: NF (50.3%), F (34.0%), SF (15.7%).Age, BMI, and Charlson Comorbidity Index increased with frailty categories (all P0.001); however, fusion length ( P = 0.247) and osteotomy rate ( P = 0.731) did not. At baseline, increasing frailty was associated with inferior Oswestry Disability Index (ODI), EuroQol 5-Dimension Questionnaire (EQ-5D), SRS-22r, Pain Catastrophizing Scale, and NRS Back and Leg (all P0.001). Greater frailty was associated with increased LOS and reduced postoperative HRQL. Controlling for complication incidence, baseline mASD-FI predicted 2 year postop scores for year ODI (b = 0.7, 0.58-0.8, P0.001) SRS (b = -0.023, -0.03 to -0.02, P0.001), EQ-5D (b = -0.003, -0.004 to -0.002, P0.001). F and SF were associated with greater odds of unplanned revision surgery and complications.Higher preoperative mASD-FI score was associated with significantly greater complications, higher rate of unplanned reoperations and lower postoperative HRQL in this investigation. The mASD-FI provides similar prognostic utility while reducing burden for surgeons and patients.

The impact of not achieving ideal realignment in the global alignment and proportion (GAP) score in adult spinal deformity (ASD) correction on clinical outcomes is understudied at present.To identify the clinical impact of failing to achieve GAP proportionality in ASD surgery.Retrospective cohort.Operative ASD patients with fusion to S1/pelvis and with pre-(BL) and 2-year (2Y) data were included. Patients were assessed for matching their 6-week (6W) age-adjusted alignment goals. 1 Patients were stratified by age-adjusted match at 6W postoperatively (Matched) and 6W GAP proportionality (proportioned: GAP-P; moderately disproportioned: GAP-MD; severely disproportioned: GAP-SD). Groups were assessed for differences in demographics, surgical factors, radiographic parameters, and complications occurring by 2Y. Multivariable logistic regression was used to assess independent effects of not achieving GAP proportionality on postoperative outcomes for Matched and Unmatched patients.Included: One hundred twenty three ASD patients. At baseline, 39.8% were GAP-SD, and 12.2% GAP-SD at 6W. Of 123 patients, 51.2% (n =63) had more than or equal to one match at 6W. GAP-SD rates did not differ by being Matched or Unmatched ( P = 0.945). GAP-SD/Unmatched patients had higher rates of reoperation, implant failure, and PJF by 2Y postop (all P0.05). Regressions controlling for age at BL, levels fused, and CCI, revealed 6W GAP-SD/Unmatched patients had higher odds of reoperation (OR: 54 [3.2-899.9]; P =0.005), implant failure (OR: 6.9 [1.1-46.1]; P =0.045), and PJF (OR: 30.1 [1.4-662.6]; P =0.031). Compared to GAP-P or GAP-MD patients, GAP-SD/ Matched patients did not have higher rates of reoperation, implant failure, or junctional failure (all P0.05). The regression results for both Matched and Unmatched cohorts were consistent when proportionality was substituted by the continuous GAP score.In ASD patients who meet age-adjusted realignment goals, GAP proportionality does not significantly alter complication rates. However, GAP proportionality remains an important consideration in patients with sub-optimal age- adjusted alignment. In these cases, severe global disproportion is associated with higher rates of reoperation, implant failure, rod fracture, and junctional failure.

Retrospective Cohort Study.Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes.The Global Alignment and Proportion(GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications.We included 412 surgical ASD patients with two-year(2Y) follow-up. Frailty was quantified using the ASD modified Frailty Index(mASD-FI). Outcomes: proximal junctional kyphosis(PJK) and failure(PJF), major mechanical complications, and 'Best Clinical Outcome'(BCO), defined as ODI15 and SRS-22 Total4.5. Logistic regression analysis established a six-week score based on GAP score,frailty and ODI US-Norms. Logistic regression followed by conditional inference tree(CIT) analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty modified GAP score.Baseline frailty categories: 57% Not Frail,30% frail,14% severely frail. Overall, 39% of patients developed PJK, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The modified ASD-FI demonstrated correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at 2Y(all P0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score(FAR Score) =0.49*mASD-FI + 0.38*GAP Score. Thresholds for the FAR score(0-13): Proportioned:3.5,Moderately Disproportioned:3.5-7.5,Severely Disproportioned:7.5. Multivariable logistic regression assessing FAR Score demonstrated associations with mechanical complications, reoperation, and meeting Best Clinical Outcome by two years(all P0.05), whereas the original GAP score was only significant for reoperation.This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity.III.

Despite adequate correction, the pelvis may fail to readjust, deemed pelvic non-response. To assess alignment outcomes(pelvic non-response[PNR], PJK, postoperative cervical deformity[CD]) following ASD surgery utilizing different realignment strategies.ASD patients with 2-year(2Y) data were included. PNR defined as undercorrected in age-adjusted pelvic tilt(PT) at 6W and maintained at 2Y. Patients classified by alignment utilities: [a] Improvement in SRS-Schwab SVA,[b] Matching in age-adjusted PI-LL,[c] Matching in Roussouly,[d] aligning Global Alignment and Proportionality(GAP) score. Multivariable regression analyses, controlling for age, baseline deformity, and surgical factors, assessed rates of PNR, PJK, and CD development following realignment.686 patients met inclusion criteria. Rates of postop PJK and CD were not significant in the PNR group(both P0.15). PNR patients less often met substantial clinical benefit in ODI by 2Y(OR: 0.6,[0.4-0.98]). Patients overcorrected in age-adjusted PI-LL, matching Roussouly, or proportioned in GAP at 6W had lower rates of PNR(all P0.001). Incremental addition of classifications led to 0% occurrence of PNR, PJK and CD. Stratifying by baseline PT severity, Low and Moderate deformity demonstrated the least incidence of PNR(7.7%) when proportioning in GAP at 6W, while severe PT benefited most from matching in Roussouly(all P0.05).Following ASD corrective surgery, 24.9% of patients showed residual pelvic malalignment. This occurrence was often accompanied by undercorrection of lumbopelvic mismatch and less improvement of pain. However, overcorrection in any strategy incurred higher rates of PJK. We recommend surgeons identify a middle ground using one, or more, of the available classifications to inform correction goals in this regard.III.

A retrospective cohort study.To assess whether patient outcomes and cost-effectiveness of adult spinal deformity (ASD) surgery have improved over the past decade.Surgery for ASD is an effective intervention, but one that is also associated with large initial healthcare expenditures. Changes in the cost profile for ASD surgery over the last decade has not been evaluated previously.ASD patients who received surgery between 2008 and 2019 were included. Analysis of covariance was used to establish estimated marginal means for outcome measures [complication rates, reoperations, health-related quality of life, total cost, utility gained, quality adjusted life years (QALYs), cost-efficiency (cost per QALY)] by year of initial surgery. Cost was calculated using the PearlDiver database and represented national averages of Medicare reimbursement for services within a 30-day window including length of stay and death differentiated by complication/comorbidity, revision, and surgical approach. Internal cost data was based on individual patient diagnosis-related group codes, limiting revisions to those within two years (2Y) of the initial surgery. Cost per QALY over the course of 2008-2019 were then calculated.There were 1236 patients included. There was an overall decrease in rates of any complication (0.78 vs . 0.61), any reoperation (0.25 vs . 0.10), and minor complication (0.54 vs . 0.37) between 2009 and 2018 (all P0.05). National average 2Y cost decreased at an annual rate of $3194 ( R2 =0.6602), 2Y utility gained increased at an annual rate of 0.0041 ( R2 =0.57), 2Y QALYs gained increased annually by 0.008 ( R2 =0.57), and 2Y cost per QALY decreased per year by $39,953 ( R2 =0.6778).Between 2008 and 2019, rates of complications have decreased concurrently with improvements in patient reported outcomes, resulting in improved cost effectiveness according to national Medicare average and individual patient cost data. The value of ASD surgery has improved substantially over the course of the last decade.

Retrospective cohort study.Understand the benefit of addressing malalignment in revision surgery for PJK.Proximal junctional kyphosis(PJK) is a common cause of revision surgery for ASD patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbo-pelvic mismatch.Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor(proximal extension of fusion alone compared to combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbo-pelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria(Global Alignment and Proportionality[GAP],Roussouly-type, and Sagittal Age-Adjusted Score[SAAS]).151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP post-revision had lower rates of recurrent PJK(23% vs. 42%;OR: 0.3,95% CI:[0.1-0.8];P=0.024). Following adjusted analysis, patients who were ideally aligned in 1 of 3 criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%;OR: 0.4,95% CI:[0.1-0.9];P=0.035) and recurrent PJF(OR: 0.1,95% CI:[0.02-0.7];P=0.015). Patients ideally aligned in 2 of 3 criteria avoid any development of PJF(0% vs. 16%, P0.001).Following revision surgery for proximal junctional kyphosis, patients with persistent poor sagittal alignment showed increased rates of recurrent proximal junctional kyphosis compared with patients who had abnormal lumbo-pelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial.

A retrospective review of a multicenter comprehensive cervical deformity (CD) database.To develop a novel risk index specific to each patient to aid in patient counseling and surgical planning to minimize postop distal junctional kyphosis (DJK) occurrence.DJK is a radiographic finding identified after patients undergo instrumented spinal fusions which can result in sagittal spinal deformity, pain and disability, and potentially neurological compromise. DJK is considered multifactorial in nature and there is a lack of consensus on the true etiology of DJK.CD patients with baseline (BL) and at least one-year postoperative radiographic follow-up were included. A patient-specific DJK score was created through use of unstandardized Beta weights of a multivariate regression model predicting DJK (end of fusion construct to the second distal vertebra change in this angle by-10° from BL to postop).A total of 110 CD patients included (61 yr, 66.4% females, 28.8 kg/m 2 ). In all, 31.8% of these patients developed DJK (16.1% three males, 11.4% six males, 62.9% one-year). At BL, DJK patients were more frail and underwent combined approach more (both P0.05). Multivariate model regression analysis identified individualized scores through creation of a DJK equation: -0.55+0.009 (BL inclination)-0.078 (preinflection)+5.9×10 -5 (BL lowest instrumented vertebra angle) + 0.43 (combine approach)-0.002 (BL TS-CL)-0.002 (BL pelvic tilt)-0.031 (BL C2 - C7) + 0.02 (∆T4-T12)+ 0.63 (osteoporosis)-0.03 (anterior approach)-0.036 (frail)-0.032 (3 column osteotomy). This equation has a 77.8% accuracy of predicting DJK. A score ≥81 predicted DJK with an accuracy of 89.3%. The BL reference equation correlated with two year outcomes of Numeric Rating Scales of Back percentage ( P =0.003), reoperation ( P =0.04), and minimal clinically importance differences for 5-dimension EuroQol questionnaire ( P =0.04).This study proposes a novel risk index of DJK development that focuses on potentially modifiable surgical factors as well as established patient-related and radiographic determinants. The reference model created demonstrated strong correlations with relevant two-year outcome measures, including axial pain-related symptoms, occurrence of related reoperations, and the achievement of minimal clinically importance differences for 5-dimension EuroQol questionnaire.

STUDY DESIGN Retrospective. OBJECTIVE To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA Surgery for correction of adult spinal deformity is often beneficial, however, in over 20% of older adults (≥65 years of age), outcomes from surgery are less desirable. METHODS We conducted semi-structured, in-depth interviews with 6 patients and 5 spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS Patients themes: (1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; (2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; (3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and (4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: (1) surgeons varied substantially in their interpretations of shared decision making; (2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; (3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and (4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness.Level of Evidence: 3.

Study Design.Retrospective review of prospectively collected data.Objective.To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common sur

This study is a comprehensive narrative of all wrong-level spine surgeries and prevention strategies employed at our institution between 2008 and 2019, and aims to provide a roadmap for developing a rigorous prevention protocol. We systematically track root cause analyses and policy changes to determine which prevention strategies are most effective.Retrospective review. We aim to create a comprehensive narrative of all wrong-level spinal surgeries (WLSS) and subsequent prevention strategies employed at our institution and provide a roadmap for developing a rigorous prevention protocol. There is currently no published evidence-based protocol to prevent WLSS. Previous studies are limited to multi-institution surgeon surveys and opinion pieces; the impact of serial interventions to eliminate WLSS is lacking. No studies have longitudinally analyzed a single institution's serial root cause analyses (RCA) of individual WLSS cases and the stepwise impact of targeted interventions to reduce WLSS occurrence. We reviewed all wrong-site spine surgeries and prevention strategies employed at our institution between 2008 and 2019, and corresponding WLSS-related RCAs were collected from institutional records. We conducted a longitudinal analysis of these reports and tracked policy implementations that resulted along with the incidence of WLSS following each policy. Fifteen WLSS were identified with 13 corresponding RCAs of 21,179 spine surgeries between 2008 and 2019. Three policy categories emerged: imaging, operating room (OR) culture, and vertebral body marking. The salient changes from each category were: requiring two immovable vertebral markers (2013); requiring intraoperative radiographs with markers and retractors positioned (2014); open-ended questioning during spinal level verification by residents and fellows (2015); and requiring an impartial radiologist to have verbal contact with the operating surgeon intraoperatively to collaboratively discuss localization (2018). Each change resulted in WLSS incidence decline (five in 2014, three in 2015, 0 in 2019). Stepwise process improvement based on WLSS case review is necessary, as no one change in standard operating procedure effectively eliminated WLSS. Improvements in communication between OR staff, surgeon, and radiologist, as well as intraoperative imaging and marking optimization all contributed to improvements in WLSS rates. By focusing on lessons learned from RCAs using this methodology, institutions can iteratively improve rates of WLSS. Level of Evidence: 4.

MINI: Despite differences in sagittal malalignment, antero-posterior pelvic translation maintained the position of T9 in line with the ankles, independently of sagittal vertical axis. Pelvic tilt was directly predicted by lower limb compensatory mechanisms. Therefore, these adaptation mechanisms being included in pelvic tilt analysis, it does not need additional consideration in the surgical planning. STUDY DESIGN Retrospective review. OBJECTIVE To investigate the role of lower limbs compensation with progressive sagittal malalignment. SUMMARY OF BACKGROUND DATA Although lower limb compensatory mechanisms are established response to progressive sagittal malalignment, their specific role and potential impact on surgical planning has not been evaluated. METHODS Single center retrospective review of full body x-rays was performed in patients of age >20 years. Parameters were measured with dedicated software. Population was stratified by 50 mm intervals of sagittal vertical axis (SVA) and one-way ANOVA was performed to compare P.shift (P.shift = anteroposterior translation of the pelvis vs. the feet) across SVA groups. Anteroposterior offset of each vertebra in relation to a vertical line extended from the distal tibial metaphysis (TM) was investigated. Linear regression was performed to predict pelvic tilt (PT) using Knee angle (KA) and P.shift, whereas controlling for pelvic incidence minus lumbar lordosis mismatch (PI-LL) and SVA. RESULTS A total of 2124 patient visits were included (PI = 55.1 ± 14.1°, PT=21.0 ± 11°, PI-LL=6.3 ± 17.3°, SVA = 29 ± 51 mm). With progressively increased SVA, P.shift decreased from 30 to -100 mm (all P

STUDY DESIGN A retrospective review of a prospectively collected database, the Nationwide Inpatient Sample (NIS), years 2003 to 2012. OBJECTIVES The aim of this study was to examine trends in the management of scoliosis in elderly (age >75 yrs) patients from 2003 to 2012. SUMMARY OF BACKGROUND DATA Scoliosis incidence rises with increasing age, and age has been shown to be an independent risk factor for surgical complications in scoliosis surgery. Previous studies have displayed increasing surgical frequency on elderly scoliotic patients in the last decade, but have not investigated complications in the same years. METHODS ICD-9 coding identified elderly (age ≥75 yrs) patients with a primary diagnosis of scoliosis undergoing lumbar fusion or decompression. Analysis of variance (ANOVA) comparisons and linear trend analysis described changes from 2003 to 2012 in surgical invasiveness (Mirza scale: levels fused/decompressed/instrumented and by approach), intraoperative complications, and Charlson Comorbidity Index (CCI). Secondary outcome measures included cost and discharge outcomes. RESULTS Eight thousand one elderly patients with ASD from 2003 to 2012 were included for analysis. Fusion incidence increased on average 13.8% per year (P

Study Design.Single-center retrospective review.Objective.The present study evaluates the effect of increasing spinal deformity deviation from age-adjusted alignment ideals on lower extremity compensation.Summary of Background Data.Although current understanding of compensatory mechanisms in adult s

STUDY DESIGN Retrospective multicenter database review. OBJECTIVE The aim of this study was to evaluate national postoperative outcomes and hospital characteristics trends from 2001 to 2010 for advanced age CSM patients. SUMMARY OF BACKGROUND DATA Recent studies show increases in US cervical spine surgeries and CSM diagnoses. However, few have compared national outcomes for elderly and younger CSM patients. METHODS A Nationwide Inpatient Sample (NIS) analysis from 2001 to 2010, including CSM patients 25+ who underwent anterior and/or posterior cervical fusion or laminoplasty. Fractures, 9+ levels fused, or any cancers were excluded. Measures included demographics, outcomes, and hospital-related data for 25 to 64 versus 65+ and 65 to 75 versus 76+ age groups. Univariate and logistic regression modeling evaluated procedure-related complications risk in 65+ and 76+ age groups (OR[95% CI]). RESULTS Discharges for 35,319 patients in the age range of 25 to 64 years and 19,097 at the age 65+ years were identified. Average comorbidity indices for patients at 65+ years were higher compared to the 25 to 64 years age group (0.79 vs. 0.0.44, P

Study design Retrospective. Objective This study assessed the feasibility of combining Oswestry and Neck Disability Index (ODI and NDI) into 1 shorter "Total Disability Index" (TDI) from which reconstructed scores could be computed. Summary of background data ODI and NDI are not pure assessments of disability related to back and neck, respectively. Because of similarities/redundancies of questions, ODI scores may be elevated in neck-pain patients and the converse is true for NDI in back-pain patients. Methods Spine patients completed ODI and NDI, and complaints were recorded as back pain (BP), neck pain (NP), or both (BNP). Questionnaire scores were compared across cohorts via descriptives and Spearman (ρ) correlations. In exploring the feasibility of merging ODI/NDI, TDI was constructed from 9 ODI and 5 NDI items. Extracting questions from TDI, reconstructed 9-item rODI and 10-item rNDI indices were formed and compared with true ODI/NDI. Results There were a total of 1207 patients: 741 BP, 134 NP, and 268 BNP. Mean ODI was 37 ± 21 and mean NDI was 32 ± 21. Patients with concurrent BP and NP had significantly more disability. Seventy-eight patients of 134 (58%) patients with NP only had at least "moderate disability" by ODI and 297 of 741 (40%) patients with back pain only, had at least "moderate disability" by NDI. ODI versus NDI correlation was ρ = 0.755; ODI versus reconstructed rODI correlated at ρ = 0.985, and NDI versus reconstructed rNDI correlated at ρ = 0.967 (P Conclusion Elevated ODI/NDI scores in patients with isolated complaints show that disability in 1 region affects scores on both surveys. This study constructed a 14-item TDI that represents every domain of ODI/NDI with exception of ODI "Sex Life." From this TDI, reconstructed scores correlated near perfectly with true scores. TDI provides a more global assessment of spinal disability and is a questionnaire that reduces the time burden to patients. The TDI allows for simultaneous assessment of back, neck, and global spinal disability.

Retrospective review of prospectively collected data.To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures.HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety.Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database.Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ± 0.04 days longer (P 0.001) and payments were $8893 ± $148 greater (P 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P 0.001). Adjusted additional LOS was 0.44 ± 0.02 and 0.38 ± 0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ± 0.11 days LOS and $4842 in payments (P 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively).HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not.3.

MINI: Despite differences in sagittal malalignment, antero-posterior pelvic translation maintained the position of T9 in line with the ankles, independently of sagittal vertical axis. Pelvic tilt was directly predicted by lower limb compensatory mechanisms. Therefore, these adaptation mechanisms being included in pelvic tilt analysis, it does not need additional consideration in the surgical planning.Retrospective review.To investigate the role of lower limbs compensation with progressive sagittal malalignment.Although lower limb compensatory mechanisms are established response to progressive sagittal malalignment, their specific role and potential impact on surgical planning has not been evaluated.Single center retrospective review of full body x-rays was performed in patients of age20 years. Parameters were measured with dedicated software. Population was stratified by 50 mm intervals of sagittal vertical axis (SVA) and one-way ANOVA was performed to compare P.shift (P.shift = anteroposterior translation of the pelvis vs. the feet) across SVA groups. Anteroposterior offset of each vertebra in relation to a vertical line extended from the distal tibial metaphysis (TM) was investigated. Linear regression was performed to predict pelvic tilt (PT) using Knee angle (KA) and P.shift, whereas controlling for pelvic incidence minus lumbar lordosis mismatch (PI-LL) and SVA.A total of 2124 patient visits were included (PI = 55.1 ± 14.1°, PT=21.0 ± 11°, PI-LL=6.3 ± 17.3°, SVA = 29 ± 51 mm). With progressively increased SVA, P.shift decreased from 30 to -100 mm (all P 0.005). Analysis of vertebral offset from the distal tibial metaphysis revealed that T9 was aligned with the TM line across all SVA groups. Prediction of PT based on PI-LL and SVA yielded R=0.76 (P 0.001). Subsequent addition of KA and P.shift as independent parameters using hierarchical multiple regression led to significant improvement in R, demonstrating the independent role of lower limbs parameters in PT prediction. KA and P.shift had a positive standardized coefficient (all P 0.05).Lower limb compensatory mechanisms increase with progressive sagittal malalignment. Anteroposterior translation of pelvis allows the T9 vertebra to remain in line with the ankle ("conus of economy"). Lower limb compensatory mechanisms are positive predictors of PT and thus do not require additional consideration in surgical realignment planning.3.

A retrospective review of a prospectively collected database, the Nationwide Inpatient Sample (NIS), years 2003 to 2012.The aim of this study was to examine trends in the management of scoliosis in elderly (age75 yrs) patients from 2003 to 2012.Scoliosis incidence rises with increasing age, and age has been shown to be an independent risk factor for surgical complications in scoliosis surgery. Previous studies have displayed increasing surgical frequency on elderly scoliotic patients in the last decade, but have not investigated complications in the same years.ICD-9 coding identified elderly (age ≥75 yrs) patients with a primary diagnosis of scoliosis undergoing lumbar fusion or decompression. Analysis of variance (ANOVA) comparisons and linear trend analysis described changes from 2003 to 2012 in surgical invasiveness (Mirza scale: levels fused/decompressed/instrumented and by approach), intraoperative complications, and Charlson Comorbidity Index (CCI). Secondary outcome measures included cost and discharge outcomes.Eight thousand one elderly patients with ASD from 2003 to 2012 were included for analysis. Fusion incidence increased on average 13.8% per year (P 0.001), surgical invasiveness by Mirza scale increased from 2.0 in 2003 to 5.9 in 2012 (P 0.001), and CCI increased from 0.77 to 1.44 (p 0.001). Over the same interval, elderly patients undergoing fusion displayed overall reduction in complications (excluding anemia)-from 26.7% to 8.6% (P 0.001); specifically, surgical complications decreased from 11.7% to 0.7% (P 0.001) and respiratory complications decreased from 6.7% to 1.4% (P = 0.004).From 2003 to 2012, surgical management of ASD in the elderly population increased in incidence and complexity, while number of patient comorbidities increased and in-hospital morbidity decreased. This may indicate increased willingness of surgeon's to operate on elderly patients, and reflect a development of overall understanding of deformity in the past decade.3.

Single-center retrospective review.The present study evaluates the effect of increasing spinal deformity deviation from age-adjusted alignment ideals on lower extremity compensation.Although current understanding of compensatory mechanisms in adult spinal deformity (ASD) is progressing due to full-body stereographic assessment, the effect of age-adjusted deformity targets on lower-limb compensation remains unexamined.ASD patients 18 years or older with biplanar full-body stereographic x-rays were included. Patients were stratified into age cohorts: younger than 40 years, 40-65 years, 65 years or older. Age-specific alignment goals (IDEAL) for pelvic tilt (PT), spinopelvic mismatch (PI-LL), sagittal vertical axis (SVA), and T1 pelvic angle (TPA) were calculated for each patient using published formulas and compared to patients' real (ACTUAL) radiographic parameters. The difference between ACTUAL and IDEAL alignment (OFFSET) was calculated. Analysis of variance compared ACTUAL, IDEAL, and OFFSET between age groups, and OFFSET was correlated with lower-limb compensation (sacrofemoral angle, pelvic shift, knee angle, ankle angle).Seven hundred seventy-eight patients with (74.1% female) were included. ACTUAL and IDEAL alignments matched for PT (P = 0.37) in patients younger than 40 years, SVA (P = 0.12) in patients 40 to 65 years and PT, SVA, and TPA (P 0.05) in patients 65 years or older. SVA and TPA OFFSETs decreased significantly with increasing age (P 0.001). Hip extension correlated with all OFFSETs in patients younger than 40 years (positively with PT, PI-LL, TPA; negatively with SVA). Knee flexion correlated with PI-LL, SVA, and TPA, across all age groups with strongest correlations (0.525 r 0.605) in patients 40 to 65 years. Ankle dorsiflexion only correlated positively with PT and PI-LL offsets in older (older than 40 years) age groups. Posterior pelvic displacement correlated positively with all OFFSET groups, and was highest (0.526 r 0.712) in patients ages 40 to 65 years.Age-adjusted ideals for sagittal alignment provide targets for patients with ASD. Offsets from actual alignment (more severe sagittal deformity) revealed differential recruitment of lower-limb extension, which varied significantly with age.3.

STUDY DESIGN Retrospective review. OBJECTIVE To evaluate preoperative variability in radiographic sagittal parameters in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA In ASD surgical planning, deformity magnitude is determined from preoperative radiographs. There are no studies evaluating the clinical relevance and timing to repeat radiographs during interval clinic visits and timing to repeat radiograph for preoperative planning. METHODS A total of 139 patients with ASD with minimum two preoperative full-body spine x-rays were included. Cervical, thoracic, lumbar, pelvic, and hip/knee sagittal alignment parameters were analyzed using dedicated spine measurement software. Patients were grouped by time intervals between x-rays: A: 8 weeks or lesser, B: 10 to 20 weeks, and C: 21 weeks or more. Changes in sagittal parameters were correlated to age and deformity magnitude (T1 pelvic angle or pelvic tilt [PT] >20°). RESULTS The cohort had mean age 59 years, mean body mass index 27, 30% men, 95 patients with no prior spine surgery, and 44 patients at minimum 9 months since prior spine surgery. There were 25 patients in group A, 38 in B, and 71 in C. All radiographic measures showed good time-based consistency at intervals less than 21 weeks (groups A and B). Group C had significant increases in PT (1.5°) and hip extension (2.1°) (P

Study Design. Retrospective review. Objective. This study follows the inpatient-stay administrative data that were collected for a cohort of thousands of patients who had spine fusion surgery in the state of New York. We sought to examine adult spinal deformity (ASD) for reoperation events with and without the use of bone morphogenetic protein-2 (BMP). Summary of Background Data. Randomized controlled trials have suggested that BMP may increase the likelihood of solid arthrodesis in spinal surgery. This would imply fewer reoperations for pseudarthrosis, but small cohort sizes are inadequate to monitor these events. Methods. The 2008–2011 New York State Inpatient Database was queried using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients age 21 years and older with a diagnosis of scoliosis and an index fusion of greater than 2 spinal motion segments were included. Patient identifiers and linkage variables were used to identify revisits. The relative risk of reoperation was calculated. The use of BMP at the initial inpatient stay was used to define the 2 cohorts for relative risk assessment. Results. A total of 3751 patients of ASD were identified in 2008. The use of BMP at the initial visit was performed at a rate of 37.6% for ASD. For posterior fusion cases longer than 8 levels, the rate of reoperation for a pseudarthrosis was 23.4%. For ASD fusions greater than 8 levels, the rate of reoperation for pseudarthrosis after using BMP at the index surgery was 5% and 33.9% when BMP was not used, a relative risk of 7.5 (P Conclusion. Using relevant inhospital patient records from the New York State Inpatient Sample, we found a 7.5-fold decrease in the risk of reoperation for pseudarthrosis after long fusions when using BMP. Decreased reoperation rates are caused by the improved fusion with the use of BMP. If subsequent unnecessary hospitals stays can be avoided, the economics of BMP use should be reexamined. Conclusion. Level of Evidence: 4

Study design Prospective and retrospective radiographic study of adult patients with spinal deformities. Objective Construct predictive models for pelvic tilt (PT) and global sagittal balance (sagittal vertical axis [SVA]) and evaluate the effectiveness of these predictive models against a group of patients after pedicle subtraction osteotomy. Summary of background data Spinal balance involves a complex interaction between the pelvis and vertebral column. In the setting of adult spinal deformity, prediction of postoperative alignment can be challenging. Methods The study included 219 adult patients treated for spinal deformity. Full-length standing films were available for all subjects. Multilinear models with a stepwise condition were used on the first group of patients (n = 179) to predict PT and global sagittal balance (measured by the SVA). Prediction models were then applied on a second group of patients (n = 40) to estimate postoperative radiographic parameters after pedicle subtraction osteotomy surgery. Differences between estimated parameters and real values were evaluated. Results Multilinear regression analysis applied on the first group of patients led to a predictive formula for PT (r = 0.93, standard error = 4.4°) using the following parameters: pelvic incidence, maximal lordosis, and maximal kyphosis. These parameters with the addition of the predicted PT were then used to predict the SVA (r = 0.89, standard error = 32 mm). Validation of predictive models (second group of patients) used pelvic incidence and postoperative sagittal curves. Postoperative PT was predicted with a mean error of 4.3° (SD 3.5°) and postoperative SVA was predicted with a mean error of 29 mm (SD = 23 mm). Conclusion This is the first study to develop and validate pragmatic predictive models for key spino-pelvic parameters (PT and SVA) in the setting of adult spinal deformity. Using a morphologic pelvic parameter (pelvic incidence) and spinal parameters modifiable through surgery (lumbar lordosis and thoracic kyphosis), postoperative sagittal alignment can be predicted.