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Objective Patients with ASD show complex and highly variable disease. The decision to manage patients operatively is largely subjective and varies based on surgeon training and experience. We sought to develop models capable of accurately discriminating between patients receiving operative versus nonoperative treatment based only on baseline radiographic and clinical data at enrollment. Methods This study was a retrospective analysis of a multicenter consecutive cohort of patients with ASD. A total of 1503 patients were included, divided in a 70:30 split for training and testing. Patients receiving operative treatment were defined as those undergoing surgery up to 1 year after their baseline visit. Potential predictors included available demographics, past medical history, patient-reported outcome measures, and premeasured radiographic parameters from anteroposterior and lateral films. In total, 321 potential predictors were included. Random forest, elastic net regression, logistic regression, and support vector machines (SVMs) with radial and linear kernels were trained. Results Of patients in the training and testing sets, 69.0% (n = 727) and 69.1% (n = 311), respectively, received operative management. On evaluation with the testing dataset, performance for SVM linear (area under the curve =0.910), elastic net (0.913), and SVM radial (0.914) models was excellent, and the logistic regression (0.896) and random forest (0.830) models performed very well for predicting operative management of patients with ASD. The SVM linear model showed 86% accuracy. Conclusions This study developed models showing excellent discrimination (area under the curve >0.9) between patients receiving operative versus nonoperative management, based solely on baseline study enrollment values. Future investigations may evaluate the implementation of such models for decision support in the clinical setting.

Sexual function is an important factor contributing to quality of life. Adult spinal deformity (ASD) patients may have sexual limitations due to lumbar spinal stiffness that may be affected by long-segment fusion.This study utilized a multicenter, prospectively defined, consecutive cohort of ASD patients. The primary outcome in this study was the Lumbar Stiffness Disability Index (LSDI) question 10: "Choose the statement that best describes the effect of low back stiffness on your ability to engage in sexual intercourse".In total, 368 patients were included in this study, including 76 men and 292 women, of which 80.7% (n = 293) underwent 9 or more level fusion and 74.4% (n = 270) had pelvic fixation. Baseline LSDI sexual function scores averaged 1.7 (SD 1.3), which improved to 1.3 (SD 1.2) at 2-year follow-up (P = 0.0008). After adjusting for confounding factors, worse LSDI sexual function score was strongly associated with worse Oswestry Disability Index, Scoliosis Research Society-22r total, and SF-36 Physical Component Summary and Mental Component Summary scores at both baseline and 2-year follow-up (p0.05 for all comparisons). Predictors of poorer baseline sexual function included older age, increased SVA, and increased back pain (p0.05 for all comparisons). Predictors of improvement in sexual function at 2-year follow-up included sagittal vertical axis improvement (P = 0.0032) and decreased postoperative back pain (P0.0001).This study found that sexual dysfunction scores due to lumbar stiffness significantly improved after surgery for ASD. Additionally, lumbar stiffness-related sexual dysfunction is strongly related to overall outcome measured by Oswestry Disability Index and Scoliosis Research Society-22r total score, highlighting the importance of sexual health on overall outcome in ASD patients.

The Lumbar Stiffness Disability Index (LSDI) assesses impact of lumbar stiffness on activities of daily living. We hypothesized that patients60 years old would perceive greater lumbar stiffness-related functional limitation following fusion for adult spinal deformity.Patients completed the LSDI and Scoliosis Research Society 22 Questionnaire, Revised (SRS-22r) preoperatively and at 2 years postoperatively. The primary independent variable was patient age60 versus ≥60. Multivariable regression analyses were used.Analysis included 267 patients. Patients60 years old (51.3%) and ≥60 years old (48.7%) were evenly represented. In bivariable analysis, patients age60 exhibited lower LSDI at baseline versus patients age ≥60 (25.7 vs. 35.5, β -9.8, P0.0001), but a directionally smaller difference at 2 years (26.4 vs. 32.3, β -5.8, P = 0.0147). LSDI was associated with lower SRS-22r total score among both age groups at baseline and 2 years (all P0.0001); the association was stronger among patients age60 versus ≥60 at 2 years. LSDI was associated with SRS-22r satisfaction scores at 2 years among patients age60 (P0.0001), but not patients age ≥60 (P = 0.2250). The difference in SRS-22r satisfaction per unit LSDI between patients60 years old and ≥60 years old was significant (P = 0.0021).Among patients with adult spinal deformity managed operatively, higher LSDI was associated with inferior SRS-22r total score and satisfaction at 2 years postoperatively. The association between increased LSDI and worse patient-reported outcome measures was greater among patients age60 versus ≥60. Preoperative counseling is needed for patients age60 undergoing adult spinal deformity surgery regarding effects that lumbar stiffness may have on postoperative function and satisfaction.

This case series examined patients undergoing caudal extension of prior fusion without alteration of the prior upper instrumented vertebra (UIV) to assess patient outcomes and rates of proximal junctional kyphosis (PJK)/proximal junctional failure (PJF).Patients eligible for 2-year minimum follow-up undergoing caudal extension of prior fusion with unchanged UIVs were identified. These patients were evaluated for PJK/PJF, and patient reported outcomes were recorded.In total, 40 patients were included. Mean follow-up duration was 2.2 ± 0.3 years. Patients in this cohort had poor preoperative sagittal alignment (pelvic incidence minus lumbar lordosis [PI-LL] 26.7°, T1 pelvic angle [TPA] 29.0°, sagittal vertical axis [SVA] 93.4 mm) and achieved substantial sagittal correction (ΔSVA -62.2 mm, ΔPI-LL -19.8°, ΔTPA -11.1°) after caudal extension surgery. At final follow-up, there was a 0% rate of PJF among patients undergoing caudal extension of previous fusion without creation of a new UIV, but 27.5% of patients experienced PJK. Patients experienced significant improvement in both the Oswestry Disability Index and Scoliosis Research Society-22r total score at 2 years postoperatively (P0.05). In total, 7.5% (n = 3) of patients underwent further revision, at an average of 1.1 ± 0.54 years after the surgery with unaltered UIV. All 3 of these patients underwent revision for rod fracture with no revisions for PJK/PJF.Patients undergoing caudal extension of previous fusions for sagittal alignment correction have high rates of clinical success, low revision surgery rates, and very low rates of PJF. Minimizing repetitive tissue trauma at the UIV may result in decreased PJF risk because the PJF rate in this cohort of patients with unaltered UIV is below historical PJF rates of patients undergoing sagittal balance correction.