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• For patients with coronary artery disease, the two most common options for intervention are a vascular stent or a coronary artery bypass graft. • Although less invasive, vascular stents may pose a long-term risk for patients undergoing further invasive procedures such as elective spine surgery. • This study aimed to provide surgeons with insight on possible major complications for elective spine surgery patients with a history of CAD. • When assessing patients with a history of coronary artery disease for elective spine fusion surgery, surgeons should be cautious of the significant risk of major complications associated with vascular stents. Revascularization is a more effective intervention to reduce future postop complications. Patients undergoing elective spine fusion surgery were isolated in the PearlDiver database. Patients were stratified by having previous history of vascular stenting (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Binary logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95 % confidence interval]). Statistical significance was set p < 0.05. 731,173 elective spine fusion patients included. Overall, 8,401 pts underwent a CABG, 24,037 pts Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease, and diabetes (p < 0.001 for all). Meanwhile, stent patients had higher rates of PVD, hypertension, and hyperlipidemia (all p < 0.001). 30-days post-op, CABG patients had significantly higher complication rates including pneumonia, CVA, MI, sepsis, and death compared to No-HP (all p < 0.001). Stent patients vs. No-HF had higher 30-day post-op complication rates including pneumonia, CVA, MI, sepsis, and death. Furthermore, adjusting for age, comorbidities, and sex Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53–2.34], P < 0.001). Additionally, controlling for levels fused, stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26–3.31], p = 0.005) and 2.02x odds within 90-days postop (OR: 2.2 [1.53–2.71, p < 0.001). With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk of experiencing a post-procedure cardiac event as dramatically as CABG. [ABSTRACT FROM AUTHOR]

• Drawbacks of current metrics compel use of novel patient-reported outcome indices. • This study developed MCID values for PROMIS, a novel patient-reported outcome metric. • Greater deformity severity by TS-CL was associated with lower MCID thresholds. Patient Reported Outcome Measurement Information System (PROMIS) instruments have been shown to correlate with established patient outcome metrics. The aim of this retrospective study was to determine the MCID for the PROMIS physical domains of Physical Function (PF), Pain Intensity (PI), and Pain Interference (Int) in a population of surgical cervical deformity (CD) patients. Surgical CD patients ≥ 18 years old with baseline (BL) and 3-month (3 M) HRQL data were isolated. Changes in HRQLs: ΔBL-3M. An anchor-based methodology was used. The cohort was divided into four groups: 'worse' (ΔEQ5D ≤ −0.12), 'unchanged' (≥0.12, but < −0.12), 'slightly improve' (>0.12, but ≤ 0.24), and 'markedly improved' (>0.24) [0.24 is the MCID for EQ5D]. PROMIS-PF, PI and Int at 3M was compared between 'slightly improved' and 'unchanged'. ROC computed discrete MCID values using the change in PROMIS that yielded the smallest difference between sensitivity ('slightly improved') and specificity ('unchanged'). We repeated anchor-based methods for the Ames-ISSG classification of severe deformity. 140 patients were included. EQ5D groups: 9 patients 'worse', 53 'unchanged', 20 'slightly improved', and 57 'markedly improved'. Patients classified as 'unchanged' exhibited a PROMIS-PF improvement of 2.9 ± 17.0 and those 'slightly improved' had an average gain of 13.3 ± 17.8. ROC analysis for the PROMIS-PF demonstrated an MCID of +2.26, for PROMIS-PI of −5.5, and PROMIS-Int of −5.4. In the Ames-ISSG TS-CL severe CD modifier, ROC analysis found MCIDs of PROMIS physical domains: PF of +0.5, PI of −5.2, and Int of −5.4. MCID for PROMIS physical domains were established for a cervical deformity population. MCID in PROMIS Physical Function was significantly lower for patients with severe cervical deformity. [ABSTRACT FROM AUTHOR]

• After weight-loss surgery, patients no longer sought care for their spinal diagnosis • Lumbar herniation had higher resolution than cervical herniation by 90 days. • Cervical degeneration and stenosis resolved at higher rates than lumbar pathologies. The effects of bariatric surgery on diminishing spinal diagnoses have yet to be elucidated in the literature. The purpose of this study was to assess the rate in which various spinal diagnoses diminish after bariatric surgery. This was a retrospective analysis of the NYSID years 2004–2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time-frame analyzed (720 days). Time from bariatric surgery until the patient's respective spinal diagnosis was no longer present was considered a loss of previous spinal diagnosis (LOD). Included: 4,351 bariatric surgery pts with a pre-op spinal diagnosis. Cumulative LOD rates at 90-day, 180-day, 360-day, and 720-day f/u were as follows: lumbar stenosis (48%,67.6%,79%,91%), lumbar herniation (61%,77%,86%,93%), lumbar spondylosis (47%,65%,80%,93%), lumbar spondylolisthesis (37%,58%,70%,87%), lumbar degeneration (37%,56%,72%,86%). By cervical region: cervical stenosis (48%,70%,84%,94%), cervical herniation (39%,58%,74%,87%), cervical spondylosis (46%, 70%,83%, 94%), cervical degeneration (44%,64%,78%,89%). Lumbar herniation pts saw significantly higher 90d-LOD than cervical herniation pts (p < 0.001). Cervical vs lumbar degeneration LOD rates did not differ @90d (p = 0.058), but did @180d (p = 0.034). Cervical and lumbar stenosis LOD was similar @90d & 180d, but cervical showed greater LOD by 1Y (p = 0.036). In conclusion, over 50% of bariatric patients diagnosed with a cervical or lumbar pathology before weight-loss surgery no longer sought inpatient care for their respective spinal diagnosis by 180 days post-op. Lumbar herniation had significantly higher LOD than cervical herniation by 90d, whereas cervical degeneration and stenosis resolved at higher rates than corresponding lumbar pathologies by 180d and 1Y f/u, respectively. [ABSTRACT FROM AUTHOR]

• Cost utility analysis of surgical treatment for ASD in different frailty states. • F and SF patients had lower Cost/QALY compared to non-frail patients at 2 years and life expectancy. • ASD surgery is a cost-effective treatment option in both NF and F/SF groups. The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states. [ABSTRACT FROM AUTHOR]

• Surgical spine patients with shorter LOS had increased rates of complications and readmissions. • Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission. • Negative outcomes may be diminished with careful patient selection. There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00–2.63], 2.33 [2.08–2.61], 2.35 [2.11–2.61], 2.27 [2.06–2.49], 2.33 [2.14–2.54], all p < 0.001). [ABSTRACT FROM AUTHOR]

• Operative intervention was associated with lower 30-day mortality and 1-year mortality compared to conservative treatment. • Increased mFI was associated with higher short-term mortality. • mFI > 3 trended higher mortality regardless of intervention. Investigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation. Patients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes. 116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention. Operative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality. [ABSTRACT FROM AUTHOR]

• Examined outcomes in spine fusion patients with a diagnosis of metabolic syndrome. • Patients were propensity score matched for total levels fused. • Patients with metabolic syndrome underwent more posterior and open surgeries. • Metabolic syndrome was an independent risk factor for postoperative complications. Metabolic syndrome is a clustering of clinical findings defined in the literature including hypertension, high glucose, abdominal obesity, high triglyceride, and low high-density lipoprotein cholesterol levels. The purpose of this study was to assess perioperative outcomes in patients undergoing spine fusion surgery with (MetS) and without (no-MetS) a history of metabolic syndrome. Included: Patients ≥18 yrs old undergoing spine fusion procedures diagnosed with MetS components with BL and 1-year follow-up were isolated in a single-center database. Patients in the two groups were propensity score matched for levels fused. 250 spine fusion patients (58 yrs, 52.2%F, 39.0 kg/m2) with an average CCI of 1.92 were analyzed. 125 patients were classified with MetS (60.2 yrs, 52%F, CCI: 3.2). MetS patients were significantly older (p = 0.012). MetS patients underwent significantly more open (Met-S: 78.4% vs No-MetS: 45.6%, p < 0.001) and posterior approached procedures (Met-S: 60.8% vs No-MetS: 47.2%, p = 0.031). Mean operative time: 272.4 ± 150 min (MetS: 288.1 min vs. no-MetS: 259.7; p = 0.089). Average length of stay: 4.6 days (MetS: 5.27 vs no-MetS: 3.95; p = 0.095). MetS patients had more post-operative complications (29.6% vs. 18.4%; p = 0.038), specifically neuro (6.4% vs 2.4%), pulmonary (4% vs. 1.6%), and urinary (4.8% vs 2.4%) complications. Binary logistic regression analyses found that MetS was an independent risk factor for post-operative complications (OR: 1.865 [1.030–3.375], p = 0.040). With longer surgeries and greater open-exposure types, MetS patients were at greater risk for complications, despite controlling for total number of levels fused. Surgeons should be aware of the increased threat to spine surgery patients with metabolic syndrome in order to optimize surgical decision-making. [ABSTRACT FROM AUTHOR]

The widely used definition for distal junctional kyphosis (DJK) includes the change in kyphosis between the lower instrument vertebra (LIV) and LIV-2 to be >10°. However, this cut-off has yet to be analyzed against other possible cut-offs in terms of accuracy, sensitivity, and specificity for various clinically relevant outcomes. Create thresholds that more accurately predict DJK than those currently used. Retrospective cohort study. Cervical deformity (CD) patients (C2-C7 Cobb >10°, CL>10°, cSVA >4cm, or CBVA >25°) with radiographic data at baseline (BL) and at least 1 year follow-up. DJK reoperation, minimal clinical important difference (MCID) for Neck Disability Index (NDI) and EQ5D. Surgically treated CD patients were enrolled into a prospective, multicenter database and evaluated at a minimum of 1-year follow-up for DJK. DJK was defined by the patient's DJK angle (DJKA) >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Sensitivity (true positive [TP]/TP+false negative [FN]), precision (true negative [TN]/(TN+False Positive [FP]), and accuracy (TN+TP/TN+TP+FN+FP) metrics were calculated from different combinations of angular changes above and below the lower instrumented vertebrae (LIV) from pre- to postop. The ability of these angular changes to predict different types of DJK failure (DJKF) [(1) reoperation for DJK (2) not meeting MCID for either NDI or Eq5D] and were compared against previously published definitions of DJK including absolute and ∆DJKA>10° and ∆DJKA >20°. A total of 160 CD patients with follow-up were included (57yrs, 29.1 kg/m2, 51.8%F). Eighteen percent of these patients developed DJK postop (33.4% 6M, 47.6% 1Y, 19% 2Y). The mean DJK angle prior to revision surgery was -1.7±7.4 (Minimum: -19.3, Maximum: 10.5). Baseline average pelvic parameters were: PT: 16.8±9.6, PI: 54.1±12.3, PI-LL: -2.0±13.5. The average cervical parameters were: TS-CL: 25.6±14.5, C2-C7: -0.9±14.4. Sensitivity, precision, and accuracy of previously used criteria of >10° to identify DJKF for outcome 1 demonstrated a sensitivity of 50%, specificity of 64.4% and an accuracy of 63.2%. For outcome 2 using this criterion resulted in a sensitivity of 55%, specificity 75.8%, and accuracy 67.3%. However, if the ∆DJKA was increased to 15.3, the predicted sensitivity for DJKF defined by reoperation was 50%, specificity 86.6% and with an accuracy of 83.6%. When DKF was defined by HRQLs the sensitivity was 35%, specificity 96.5% and accuracy of 71.4%. This newly established cut-off had greater ability to correctly identify true positives than the 20° cut-off (45.8% vs 27.1%), as well as for true negatives when compared to the 10° (39.2% vs 34.2%). A subanalysis identified 40.6% of patients with a DJKA >10° to be not clinically meaningful. When increasing the angle to the proposed 15.3° only 35.7% are not clinically meaningful. The newly established cut-off for DJK failure (∆DJKA>15.3°) demonstrated greater sensitivity, specificity, and precision than the previously established criteria of 10° when analyzing distal junctional kyphosis failure as described by reoperations or clinical deterioration. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

As surgery is increasingly recommended for patients with spinal instability and neurologic deterioration secondary to central cord syndrome (CCS), it is important to investigate the impact age has on postoperative complication rates. Investigate associations of age and surgical decision and timing of procedure. Retrospective review of Health care Cost and Utilization Project's Nationwide Inpatient Sample (NIS). CCS patients. Surgical timing and postop complications. CCS patients (ICD-9 codes 952.03, 952.08, 952.13, 952.18) were isolated in the NIS database 2007-2016. As appropriate, analysis of variance and chi-squared tests compared demographics, and Charlson Comorbidity Index (CCI) scores. Patients were then stratified by age into 4 percentiles (1st: 13-48, 2nd: 49-50, 3rd: 59-68, 4th: 69-90). Surgical decision-making such as approach and surgical timing were analyzed for their association with postoperative complications via logistic regressions controlling for CCI. An age cutoff in relation to postop complications was identified via Receiver Operating Curve (ROC). There were 5,725 CCS patients included (59.5years, 1.3 CCI, 26% Female). By age percentile, those that were in the lowest had greater rates of decompressions (71.8%), fusions (88.4%), combined approach (5.1%), anterior approach (64.4%), and 9+ levels fused (3.5%; all p<0.001). Those in the highest percentile had greater rates of posterior approach (38.4%) and greater CCI (1.8), whereas those in the 3rd percentile had the greatest fusion rate for 4-8 levels (11.9%; all p<0.001). Controlling for CCI, those in the 3rd percentile for age were associated with posterior perioperative complications (1.8[1.4-2.3]), those in 2nd were associated anterior complications (7[5.2-9.5]), and those in the lowest percentile group were associated with combined approach complications (3.4[1.8-6.4-; p<0.05). More specifically, patients in the 4th percentile had increased odds at developing neurologic issues (OR:2.6) whereas those in the 3rd had greater odds of cardiac complications postop (OR:3.6; p<0.05). Disposition status was also affected by age, with those in the highest percentile experiencing greater rates of death after being discharged (12.1[9.5-15.2; p<0.001). Patients in the 4th percentile had the most extreme loss of function (7.4[6.5-8.5]; p<0.05). By surgical timing, there was no increased rate of complications among the age groups for same day procedures. However, delaying surgery by 2 or 3 days was identified to be associated with increased complications for the lowest percentile group (OR:5.2 and OR:7.1 respectively; p<0.05). With a greater increase in delay of surgery of 8-14 days (3.9[2.1-7.3]) and 15+ (14.1[8.4-23.7]) were identified to be significant procedure time points of developing complications for patients in the 3rd percentile. Overall, patients>59 years had an increased likelihood of postoperative complication development (AUC: 0.5, p=0.002). Age overall played a role in postoperative complications when >59 years. It also played a significant role in surgical timing and surgical approach. Adequately stratifying patients diagnosed with Central Cord Syndrome in accordance to their age profile can minimize postoperative complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Chiari malformations (CM) are congenital or acquired hind brain anomalies with resultant cerebellar tonsillar herniation through the foramen magnum. These malformations are classified by the severity of the disorder as Types I-IV, each type presenting with associated features and anomalies. Despite significant research on Chiari malformations, clinical features and management options have not yet conclusively evolved. This study aims to identify different surgical variables and complication rates for CM sub-types. Retrospective cohort study of HCUP's KID (Kids' Inpatient Database), A total of 35,073 Chiari Malformation patients in KID during the years of 2003-2012. Perioperative outcomes in surgical spine patients (patients). The KID database was queried for diagnoses of operative Chiari Malformation from 2003-2012 by ICD-9 codes. Differences in preoperative demographics (age/BMI) and perioperative complication rates between patient cohorts were assessed using Pearson's chi-squared tests and T-tests when necessary. Binary logistic regression, which controlled for age and LOS was used to assess the contribution Chiari's has on complication rate. Level of significance was set to p<0.05. There were 34,982 Chiari patients isolated from KID (3.17years ±6.4, 49.5F%). Of these, 39.4% were type I, 6.1% were type III, and 55.4% were type IV. Also, 5.6% of these Chiari patients experienced complications (CM-I=8.2%, CM-III=5.5%, CM-IV=3.7%; p=0.00). CM -I and IV primary diagnoses increased over time (Type I: 31.1% to 38.4%, Type IV: 17.3% to 20.8%; all p<0.001). Common surgeries performed for CM-I were: decompressions (28.6%), laminectomies (27.8%), and spinal fusions (2.2%: 2-3lvl=36.2%, 4-8lvl=12.3%, 9+=21.9%). CM – I patients were more likely to undergo surgical treatment than the other types (63.4% vs 28.6%, 15.1%; CM-III and CM –IV, respectively). The most prevalent comorbidities among the groups were anemia (I:2.4%, III:0.5%, IV:0.4%; p=0.00), cerebrovascular (I:7.3%, III:1.1%, IV: 1.0%; p=0.00), and pulmonary (I:11.7%, III: 4.0%, IV: 11.0%; p=0.00). CM-1 patients experienced more complications than CM-III and CM-4 (8.2%, 5.5%, 3.7%; all p<0.05). CM-III patients were most likely to be transferred out to an acute care hospital as opposed to other types (Type 3: 6.8% vs Type 1: 2.9% and Type IV: 4.1%; p=0.00). CM- IV had the longest length of stay with the mean being 9.91 days vs type I: 6.89 and Type 3: 7.49. CM-I patients had the following concurrent diagnoses: 11.9% syringomyelia/syringobulbia, 5.4% scoliosis, 2% hydrocephalus, and 2.2% tethered chord syndrome. There were12.0% of CM-III patients concurrently diagnosed with hydrocephalus, 1.2% tethered chord syndrome, and less than 1% had either scoliosis or syringomyelia/syringobulbia. Surgeries for CM- I, and IV increased from 2009-2012 (7.6% to 10.3%, p=0.00) and 2004-2012 (3.9% to 4.5%, p=0.00) while, the complication rates significantly decreased (1.5% to 1.3%, p<0.05; 0.6% to 0.5%); respectively. LOS (1.04 [1.04-1.03]; p=0.00) was significantly associated with developing complications in CM-1 patients. However, when controlling for age and LOS, CM-3 patients that underwent a laminectomy (4.9[10.5-2.28]; p=0.00) and CM-4 patients that underwent a spinal decompression (34.2[108.6-10.8]; p=0.00) were significantly associated with receiving a complication. CM-1 patients were identified to have greater complication rates irrespective of procedure, most of which were less serious than other subtypes, type while CM-III and CM-IV were identified to be affected by receiving a more extensive decompressions and have more serious adverse complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

NSQIP Surgical Risk Calculator is a web-based decision aid and informed consent tool widely used by surgeons and their patients. This application creates patient-specific risks for those planning to undergo a procedure. Despite its wide use, minimal studies have validated the external applicability of the NSQIP calculator, in the setting of adult spinal deformity. Identify NSQIP risk calculator usability in a population of adult spinal deformity (ASD) patients from a single institution database (Quality). Retrospective cohort study of patients with adult spinal deformity between 2011-2018. Adult spinal deformity patients. Any Complication rate, cardiac complication, SSI, UTI, return to OR and length of stay (LOS). ASD patients were isolated in Quality (2011-2018). CPT codes for ASD patients were utilized in the NSQIP calculator in order to create baseline expectations for patient outcomes. 7 variables shared among Quality and NSQIP risk calculator were identified for average predictive values. The same perioperative outcomes collected from the NSQIP calculator was then analyzed in the Quality database. Pts were further stratified by frailty (not frail [NF]<0.03, frail[F] 0.3-0.5, severely frail [SF]>0.5). Brier scores were calculated for each variable in order to validate the calculator's predictability in Quality. Having a score closer to 1 means the NSQIP calculator is not predictive of that specific outcome. A score closer to 0 means the NSQIP calculator was a predictive tool for that factor. A total of 1,606 ASD patients were isolated from the Quality (48.7yrs, 63.8%F, 25.8 kg/m2). 33.4% received decompressions and 100% received a fusion. Of these Quality patients, 15.1% had past medical history of hypertension, 3.1% malignant cancer, 5.2% diabetes, 2.6% connective tissue disease and 2.8% chronic pulmonary disease. The average ASD outcome predicted by the NSQIP risk calculator predicted lower rates for NSQIP patients for return to OR (0.8% vs 2.4%), LOS (2.5d vs 6.5d), total complication rate (11.5% vs 16.5%), and cardiac (0.34% vs 1.9%) than Quality patients. The single institution did have lower UTI and SSI outcomes (1.7% vs 2.85%; 1% vs 1.8% respectively). The calculated Brier scores identified the calculator's predictability for each factor: complication total (0.78), cardiac (0.99), SSI (0.99), UTI (0.96), and return to OR (0.92). The only variable predictive among ASD patients was death with a Brier score of 0 in both groups. This was also the only factor among NF patients (Brier score:0). The NSQIP calculator predicted outcomes for F patients that were lower than those identified in the single institution and therefore, didn't have much usability in this population. The NSQIP calculator is not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to OR, SSI, UTI and cardiac that are typically associated with poor patient outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

For patients undergoing a cervical spine procedure, the effect of a shoulder injury on perioperative outcomes is not well understood. Our study aimed to investigate the impact shoulder injuries have on perioperative outcomes for elective cervical spine surgery patients. To evaluate the effect of concomitant shoulder injuries on perioperative outcomes of elective cervical spine surgery. Retrospective review of a national patient database between 2007-2017. A total of 1,482,311 elective cervical spine surgery patients. Comorbidity burden, invasiveness, perioperative complications, length of stay (LOS), total hospital charges. Patients undergoing elective cervical spine surgery were isolated with ICD-9 diagnosis codes. Cervical procedure (CP) patients with concurrent shoulder diagnosis(S-Dx) were further isolated. Means comparison tests compared differences in demographics, surgical, and perioperative outcomes between those who had a cervical procedure and a concurrent shoulder diagnosis (CP/S-Dx) and those who had a cervical procedure with no shoulder diagnosis (CP). Logistic regression analysis assessed the odds of complication associated with a shoulder diagnosis, controlling for age and surgical invasiveness. 1,482,311 elective cervical spine surgery patients were included. Overall, 17,873(1.2%) patients underwent a CP and had a concurrent S-Dx. CP and S-Dx patients compared to only CP patients were significantly younger and male (both p<0.05). CP/ S-Dx patients presented with higher rates of alcohol abuse, anemia, rheumatoid arthritis, congestive heart failure, chronic pulmonary disease, drug abuse, hypertension, and liver disease (all p <0.05). CP/S-Dx patients underwent more invasive procedures (p<0.001) including spinal fusions and osteotomies (both p<0.05) but less decompressions (p<0.001). CP/S-Dx patients had higher overall perioperative complication rates, including higher rates of anemia, cardiac, respiratory, DVT and experienced a longer LOS (5.97 days vs 3.71 days) (all p<0.05). CP/S-Dx patients had higher rates of nonhome discharge (36.7% vs 25.8%) and incurred greater total hospital charges ($101,899 vs $73,572; both p<0.001). Adjusting for age and invasiveness, patients undergoing a cervical procedure with a shoulder diagnosis were associated with increased odds of any complication (OR:1.3[1.3-1.4]; p<0.001). Patients with a concurrent shoulder diagnosis undergoing a cervical spine procedure were 30% more likely to experience a perioperative complication compared to those without a shoulder injury. Prior to proceeding with surgery, providers should consider the effect of shoulder injuries on outcomes of cervical spine procedures. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Incorporation of open and MIS robotic techniques in spine surgery has been growing over the past decade, resulting in altered surgical techniques and the need for newly developed skills. With the initial learning curve involved in using this new technology, the upfront risk of complications and poor outcomes during the learning process has been understudied in the literature. To evaluate the initial risk of complications with the incorporation of robotic assisted spine surgery. Retrospective review of a national patient database between 2007-2016. A total of 3,759,824 elective spine surgery patients. Comorbidity burden, perioperative complication rates, year-to-year complications, mechanical complications. Inclusion criteria: elective spine surgery procedures from 2007-2016 as defined by ICD-9-CM and ICD-10-CM codes. Exclusion criteria: emergency, trauma or nonelective surgery. Descriptive statistics assessed demographic information. Rates of open and MIS robot-assisted procedures were assessed, as well as trends in postoperative complications and length of stay. Logistic regressions were performed to see if robotic use was independently predictive of a postoperative complication. The study included 3,759,824 elective spine surgery patients. Overall, 4,185 patients underwent robotic spine surgery (0.1%). There was a significant increase from in robotic surgery cases from 2010 to 2016 with 11 patients in 2010 to 1,535 patients in 2016 (p<0.001). During this time, 93% of robotic spine cases were open compared to 7% MIS (p<0.001). Relative to nonrobotic patients, robotic-spine patients presented with higher rates of anemia, rheumatoid arthritis, uncomplicated diabetes, hypertension, hypothyroidism, fluid and electrolyte disorders (all p<0.001). Overall, robotic-spine patients had higher overall perioperative complication rates, including cardiac, urinary and anemia (all p<0.001). Postoperatively, year-to-year overall complications in robotic surgery patients increased from 25% in 2011 to 29.6% in 2016 (p <0.001), with a high of 31.8% in 2015. Robotic-open cases compared to robotic-MIS cases were shown to have significantly higher overall complications (28.2 vs 13.6%, p<0.001), including complications associated with anemia and mechanical complications (both p<0.001). The rise of robotic assisted spine surgery has yielded a concurrent rise in perioperative complications as surgeons adjust to this new technology. Until the learning curve lessens for incorporation of robotic techniques in spine surgery, providers should weigh MIS or open robotic procedures with an eye towards perioperative complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

• Defective anatase TiO 2 , prepared by chemical vapor condensation (CVC) method. • Pt supported over defective TiO 2 resulted in enhanced removal of HCHO. • Oxygen vacancies (F centers) were main detected defects before and after Pt impregnation. • The defective domains played an important role in enhanced and stable activity. Sustainable and effective formaldehyde (HCHO) remediation at room temperature has significant potential in next-generation indoor environment purification technology. Herein, defective anatase TiO 2 was synthesized using chemical vapor condensation (CVC) and was subsequently impregnated with 0.08 wt% Pt. The resulting Pt/CVC-TiO 2 catalyst was used for the room-temperature conversion of HCHO and exhibited a HCHO removal efficiency of 80% under continuous flow conditions (GHSV 100,000 cm3 h−1 g cat −1) with an initial concentration of 10 ppm with good stability over 600 min. The characterization results confirmed the metallic oxidation state (Pt0), oxygen vacancies (mainly F centers), disordered domains, and strong interaction between Pt and defective TiO 2 were essential for high activity. Moreover, electron paramagnetic resonance (EPR) analysis showed the consistent stability of the defective domains of CVC-TiO 2 , imparting catalytic stability over multiple cycles. This study highlights the synergistic relationship between oxygen vacancies in the TiO 2 support and the resulting HCHO oxidation functionality. [ABSTRACT FROM AUTHOR]

Recent studies have suggested that for patients with chronic neck pain, both psychological and psychosomatic symptoms need to be addressed as psychological distress is associated with poor outcomes in these patients. The fear avoidance model has been used to explain how maladaptive thoughts and behaviors contribute to chronicity and disability. Certain mental health scores have been previously analyzed in patients with pathologies in different spinal regions. However, these rates have yet to be assessed against patients undergoing cervical spine surgery. Identify the psychological burden among patients undergoing surgical treatment for their symptomatic cervical degenerative disease. Single-center prospective double-blinded, randomized control trial that consists of patients undergoing surgical arthrodesis for 3 single- or multilevel cervical disease, resulting in cervical radiculopathy. This study included 47 symptomatic cervical degenerative disorders patients. Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS). Neck Disability Index (NDI), EuroQol Five Dimensions (EQ5D). A total of 47 patients age >18 with symptomatic cervical degenerative disease were included and those with active depression or history of major depression were excluded from the study. Basic demographics and baseline HRQLs (NDI, EQ5D, PCS, FABQ) were assessed via descriptive analyses. Patient psychosomatic scores that measure preoperative pain catastrophe and fear avoidance of procedure (PCS, FABQ) were compared to previously published benchmarks in a lumbar spine population. These mental health components and disability were further stratified by their severity as previously published (PCS >30; FABQ >34). Correlations assessed the relationship between these mental health components and severity of disability described by NDI (Not Disabled=0-4, Mild=5-14, Moderate=15-24, Severe=25-34, Complete=34+). Furthermore, logistic regressions were analyzed to determine whether NDI was an independent predictor of psychological burden described by PCS and FABQ. Forty-seven patients were enrolled (age 53.6 years, BMI 29.4 kg/m2). 32% of these patients were diagnosed with radiculopathy, 26% with myelopathy, and 42% with concomitant imaging diagnosis (hnp, ddd, spondylosis all with or without central stenosis). These patients were all scheduled to undergo spinal fusions with decompression and had failed at least 3 months of conservative treatment. The average number of levels fused was 2.27±1.4. At baseline, the average PCS was 27.4 and FABQ: 40. By overall health metrics, the patient population had an average EQ5D score of 9.3 and an NDI of 25.6. 57.1% of patients had a severe FABQ, 40.8% had a severe PCS, and 27.7% had a severe NDI score. As compared to historical controls of lumbar patients, the patients in this study had greater levels of psychosomatic pathology measured by FABQ (40 vs 17.55; p<0.001) and PCS (27.4 vs 19.25; p<0.001). PCS was positively correlated with FABQ scores (r=0.55; p<0.001). Increasing neck disability was correlated with greater PCS measured disability (Overall r=0.7, Complete r=0.58; p<0.05). Being completely disabled was also identified to have a significant relationship with having a severe PCS score independent of levels fused and diagnosis (OR=11.7[1.5-90.5]; p=0.019). This trend was similarly identified for FABQ (Overall r= 0.5, Complete r=0.4; all p<0.05). Age was also not a significant predictor for baseline severe PCS and FABQ nor were diagnosis and presence of stenosis. Cervical spine patients have an overall great amount of mental health pathology; however, a large portion of these patients also have high fear avoidance beliefs and pain catastrophizing at baseline. These rates were identified to be higher than previously identified benchmarks of lumbar spine patients. Because this study excluded patients with an official diagnosis of depression or other psychological condition, it is reasonable to say that the mental health pathology of patients undergoing cervical surgery is greatly underestimated and should warrant preoperative treatment to help mitigate these mental health scores at baseline. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Distal junctional kyphosis (DJK) remains a primary concern for surgeons performing cervical deformity (CD) surgery. Postoperative complications from CD surgeries often render patients with worse recovery profiles which require reoperation. It is paramount to understand possible DJK recovery profiles for various types of surgical patients. Identify if DJK patients successfully recover from treatment/reoperation. Retrospective review of prospectively collected database. This study included 145 cervical deformity (CD) patients with baseline and 1-year follow-up. Complications;reoperations; HRQL, alignment. CD patients(patients) were identified if they developed DJK. DJK angle (DJKA) was defined as >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Patients were stratified into two groups: 1) those who received a reoperation for DJK (Reop DJK) and those that did not have DJK (no DJK). Normalized HRQL scores at baseline and follow-up intervals (3 months, 6 months, 1 year, 2 years) were generated. Normalized HRQLs were plotted and area under the curve was calculated, generating one number describing overall recovery (Integrated Health State [IHS]). A total of 145 CD patients included. Of these patients, 32% developed DJK postop (56 years, 28.5kg/m2, 53% Female) with 12.8% of these cases being severe. By DJK occurrence: 24.2% within 3 months, 45.4% at 6 months, 31.4% by 1 year. Of these DJK patients, 25.5% received a reoperation. Upon presentation, Reop DJK patients had a worse PI-LL (-11.0 vs.11), worse NSR-Neck (8.7 vs 6.9), and a worse NDI (65.7 vs 53.9; all p<0.05). After receiving operation for their DJK, these patients displayed a worse pain recovery profile identified by their IHS-adjusted score when compared to No DJK patients for NRS-Neck between baseline to 3 months (19.7 vs 11.5; p<0.05). If these patients remain hyperkyphotic (T1-T12) postop, the IHS-adjust scores identified worse long-term recovery (3 months to 2 years) as identified by their EQ5D (52.5 vs 57.5; p<0.05). However, if reop DJK patients are matched according to their age-adjusted SVA (Lafage et al), they were identified to have better short-term recovery than DJK reop patients who were not matched by their NSR-Neck (7.0 vs 11; p<0.05) and then eventually normalizes with the latter's recovery course (p>0.05). Having DJK and not receiving a reop did not have much of an effect on recovery despite DJK angle, however; when compared to DJK reop, when nonop DJK angle was greater than 20°, the IHS-score mJOA adjusted resulted in greater long-term recovery (nonReop:59.9 vs Reop: 48.4; p<0.05). Of the total DJK patients in this study, 25.5% received a reoperation. These patients had a worse pain recovery profile than non-DJK patients. However; when matched to their age-adjusted SVA, reop DJK patients were shown to have an improved short-term recovery than if they went unmatched according to their IHS-adjusted NSR-Neck. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background: Little is known of how frailty, a dynamic measure of physiological age, progresses relative to age or disability status. Operative treatment of adult spinal deformity (ASD) may play a role in frailty remediation and maintenance.Purpose: Compare frailty status, severe frailty development, and factors influencing severe frailty development among ASD patients undergoing operative or nonoperative treatment.Design: Retrospective review with maximum follow-up of 3 years.Setting: Prospective, multicenter, ASD database.Participants: Patients were consecutively enrolled from 13 participating centers.Inclusion Criteria: ≥18 years undergoing either operative or nonoperative treatment for ASD, exclusion criteria: spinal deformity of neuromuscular etiology, presence of active infection, or malignancy. The mean age of the participants analyzed were 54.9 for the operative cohort and 55.0 for the nonoperative cohort.Outcomes Measures: Frailty status, severe frailty development, and factors influencing severe frailty development.Methods: ASD patients (coronal scoliosis ≥20°, sagittal vertical axis (SVA) ≥5 cm, Pelvic Tilt (PT) ≥25°, or thoracic kyphosis ≥60°) >18 y/o, with Base Line (BL) frailty scores were included. Frailty was scored from 0 to 1 (not frail: <0.3, frail 0.3-0.5, severe frailty >0.5) through the use of ASD-frailty index (FI) which has been validated using the International Spine Study Group (ISSG) ASD database, European Spine Study Group ASD database, and the Scoli-RISK-1 Patient Database. The ISSG is funded through research grants from DePuy Synthes and individual donations and supported the current work. Operative (Op) and Nonoperative (Non-Op) patients were propensity matched. T-tests compared frailty among treatment groups and BL, 1, 2, and ≥3 years. An actuarial Kaplan-Meier survivorship analysis with log-rank (Mantel-Cox) test, adjusting for patients lost to follow-up, determined probability of severe frailty development. Multivariate Cox Regressions gauged the effect of sagittal malalignment, patient and surgical details on severe frailty development.Results: The analysis includes 472 patients (236 Op, 236 Non-Op) selected by propensity score matching from a cohort of 1,172. Demographics and comorbidities were similar between groups (p>.05). Op exhibited decreased frailty at all follow-up intervals compared with BL (BL: 0.22 vs Y1: 0.18; Y2: 0.16; Y3: 0.15, all p<.001). Non-Op displayed similar frailty from BL to 2Y follow up, and increased frailty at 3Y follow up (0.23 vs 0.25, p=.014). Compared with Non-Op, Op had lower frailty at 1Y (0.18 vs 0.24), 2Y (0.16 vs 0.23), and 3Y (0.15 vs 0.25; all p<.001). Cumulative probability of maintaining nonsevere frailty was (Op: 97.7%, Non-Op: 94.5%) at 1Y, (Op: 95.1%, Non-Op: 90.4%) at 2Y, and (Op: 95.1%, Non-Op: 89.1%) at ≥3Y, (p=.018). Among all patients, baseline depression (hazard ratio: 2.688[1.172-6.167], p=.020), Numeric Rating Scale (NRS) back pain scores (HR: 1.247[1.012-1.537], p=.039), and nonoperative treatment (HR: 2.785[1.167-6.659], p=.021) predicted severe frailty development with having a HR>1.0 and p value<.05. Among operative patients, 6-week postoperative residual SVA malalignment (SRS-Schwab SVA+modifier) (HR: 15.034[1.922-116.940], p=.010) predicted severe frailty development indicated by having a HR>1.0 and p value <.05.Conclusions: Non-Op patients were more likely to develop severe frailty, and at a quicker rate. Baseline depression, increased NRS back pain scores, nonoperative treatment, and postoperative sagittal malalignment at 6-week follow-up significantly predicted severe frailty development. Operative intervention and postoperative sagittal balance appear to play significant roles in frailty remediation and maintenance in ASD patients. Frailty is one factor, in a multifactorial conservation, that may be considered when determining operative or nonoperative values for ASD patients. Operating before the onset of severe frailty, may result in a lower complication risk and better long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

Investigate the differences in spine surgery cost for metabolic syndrome patients. Included were patients ≥18 undergoing fusion. Patients were divided into cervical, thoracic, and lumbar groups based on their upper instrumented vertebrae (UIV). Metabolic syndrome patients (MetS) included those with body mass index >30, diabetes mellitus, dyslipidemia, and hypertension. Propensity score matching for invasiveness between non-MetS and MetS used to assess cost differences. Total surgery costs for MetS and non-MetS adult spinal deformity patients were compared. Quality-adjusted life years (QALYs) and cost per QALY for UIV groups were calculated. A total of 312 invasiveness matched surgeries met inclusion criteria. Baseline demographics and surgical details included age 57.7 ± 14.5, 54% female, body mass index 31.1 ± 6.6, 17% anterior approach, 70% posterior approach, 13% combined approach, and 3.8 ± 4.1 levels fused. The average costs of surgery between MetS and non-Mets patients was $60,579.30 versus $52,053.23 (P < 0.05). When costs were compared between UIV groups, MetS patients had higher cervical and thoracic surgery costs ($23,203.43 vs. $19,153.43, $75,230.05 vs. $65,746.16, all P < 0.05) and lower lumbar costs ($31,775.64 vs. $42,643.37, P < 0.05). However, the average cost per QALY at 1 year was $639,069.32 for MetS patients and $425,840.30 for non-Mets patients (P < 0.05). At life expectancy, the cost per QALY was $45,456.83 versus $26,026.84 (P < 0.05). When matched by invasiveness, MetS patients had an average 16.4% higher surgery costs, 50% higher costs per QALY at 1 year, and 75% higher cost per QALY at life expectancy. Further research is needed on the possible utility of reducing comorbidities in preoperative patients. [ABSTRACT FROM AUTHOR]

Restoring sagittal alignment in adult spinal deformity (ASD) surgery is a common goal to improve patient clinical outcomes and minimize long-term complications. Recent enthusiasm has suggested that achievement of global alignment and proportionality alignment may influence mechanical failures and as such may potentially influence ultimate outcomes. To investigate which components of the GAP score are most associated with patient-reported and clinical outcomes. Retrospective cohort study of prospective, multicenter ASD database. This study included 227 ASD patients. Complications; health-related quality of life (HRQL): ODI, SRS-22r, SF-36. Operative ASD patients (scoliosis >20°, SVA>5cm, PT>25°, or TK>60 °,) with a fusion at L1 or higher with available baseline and 2-year radiographic and HRQL data were included. Multivariate analysis (MVA) was used to find an association between the global alignment and proportionality (GAP) score higher risk individual categories: moderately disproportioned (MD) - (GAP >2 and <7) and severely disproportioned (SD) - (GAP >7). Severe sagittal deformity was defined by a ++ in SRS-Schwab for SVA, or PI-LL. Mechanical complications excluded PJK. A total of 227 ASD patients met the inclusion criteria (59.9yrs±14.0, 79%F, BMI: 27.7 kg/m2 ±6.0, ASD-FI: 3.3±1.6, CCI: 1.8 ±1.7). Surgically, patients had mean levels fused of 11.1±4.4, length of stay (LOS) of 7.9 days±4.4, estimated blood loss (EBL) of 1577 mL, operative time of 377 min, with 63% undergoing an osteotomy. In the full cohort, controlling for age, and CCI, MVA showed no association of GAP MD or SD patients with PJF, or mechanical complications, (p>0.05) but MD patients showed a positive correlation with development of PJK [OR: 2, 95% CI: 1-3.7, p<0.05]. In a cohort of patients with severe sagittal deformity, GAP MD (4.2[1.3-13.4]) and GAP SD (3.3[1.06-10]) criteria was predictive of PJK by 2 years, and in a cohort of patients 65 and older, GAP MD (5[1.4-18], p=.014) and GAP SD (3.6[1-12], p=.04) were also predictive of 2-year PJK development. There was no association with PJF or mechanical complications. In a cohort of patients with a history of prior fusion, or in patients less than 65 years of age, there was no correlation of GAP MD/GAP SD with PJK, PJF, or mechanical complications. The continuous 6W GAP score, as well as the GAP categories, did not show significant correlations with patient reported outcomes at 2 years. Since the introduction of the global alignment and proportionality (GAP), literature has been inconclusive on the utility of the GAP score in clinical practice. Our study shows that the GAP score had strong predictive potential for proximal junctional kyphosis (PJK), specifically, in patients with severe baseline sagittal malalignment and/or those 65 and older, and, may have less utility in younger patients, or those with a previous fusion. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Adult spinal deformity correction has been demonstrated to result in improved pain and function. However, the financial implications of these procedures on health care systems can be profound, particularly when subject to complications/failures. Evaluate pre- and postoperative patient and surgical metrics, and to elucidate their relationship to total health care costs. Retrospective. A total of 183 Adult Spinal Deformity (ASD) patients. Utility Gained, Oswestry Disability Index (ODI), Cost, Quality Adjusted Life Year (QALY), Cost Effectiveness (Cost/QALY). The cohort was isolated to those who had baseline and 2-year Health Related Quality of Life (HRQL) data. Total cost was derived from PearlDiver, which accounts for costs within 30 days (including length of stay and mortality) differentiated by surgical approach, complications, and reoperation. Cost per Quality Adjusted Life Year (QALY), was calculated via published methods from ODI. Patients who did not have a positive utility gained indicated cost ineffectiveness. This cohort of patients (utility lost, UL) was compared to those who were cost effective (utility gained, UG) by means comparison analyses (chi-squared ANOVA) to determine the differentiating factors between cost ineffectiveness and effectiveness. Conditional Inference Tree analysis (CIT) ranked associated factors. There were 183 patients, 53 (29.0%) UL and 140 (20.6%) UG. Patients in these groups differed in baseline radiographic and HRQL measurements as well as complication rates:Pelvic Tilt: UL=17.68; UG=24.25; p=0.001PI-LL: UL=3.52; UG=12.97; p=0.013L1-S1: UL=50.39; UG=41.06; p=0.021TPA: UL=14.91; UG=22.29; p=0.002SVA: UL=25.06; UG=53.01; p=0.011Any Complication: UL=32.1%; UG=48.5%; p=0.043Major Complication: UL=5.66%; UG=23.1%; p=0.005BL ODI: UL=18.96; UG=34.47; p<0.001Y2 ODI: UL=28.61; UG=16.88; p<0.001After CIT, the factors most associated with UL in descending order: BL pelvic tilt, BL T1 PA, Age, CCI, BL L1S1, operative time, number of major and minor complications, BL T2-T12 thoracic kyphosis, BL TS-CL, BL Frailty, BL cSVA. Factors that were most influential in a high overall cost in decreasing order by CIT: number of complications, number of reoperations, number of major and minor complications, BL cSVA, osteotomy, frailty, body mass index, LOS. Patients that had Utility Lost had better HRQL scores and less severe radiographic measures at baseline compared to patients that were Utility Gained. This possibly indicates that instance of complications, despite being lower than those of Utility Gained, outweighed the benefits of surgery for Utility Lost patients who had less severe radiographic measures. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Thoracolumbar malalignment is often seen in patients presenting with cervical deformities. For operative cervical deformity (CD) patients, it is unknown when the thoracic spine should be included in the construct. To investigate the CD patients in whom fusion to the thoracic spine was warranted. Retrospective cohort study. A total of 72 CD patients. Radiographic parameters; complications, distal junctional kyphosis [DJK], reoperation; Health-Related Quality-of-Life [HRQLs]: NDI, NRS-neck, mJOA. Included: operative CD patients (C2-C7 lordosis < -15°, TS-CL >35°, segmental cervical kyphosis >15° across any 3 vertebra between C2-T1, C2-C7 SVA >4cm, McGregor's slope >20°, or CBVA > 25°) with baseline (BL) and up to 2-year (2Y) data. Patients with UIV at or above C4 and LIV extending beyond C7 into the thoracic spine were isolated (CT fusions). CT fusion patients were further stratified to upper and lower thoracic LIVs: T1-T4 [Short Fusion], beyond T4 [Long Fusion]. CT fusion patients were identified as having an optimal outcome at 2-year postop if they 1) did not have DJF and 2) had Virk et al. good clinical outcome [≥2 of the following: NDI <20 or meeting MCID, mild myelopathy (mJOA ≥14), NRS-Neck ≤5 or improved by ≥2 points from baseline]. Univariate analysis compared patients with long fusion and optimal outcome (L/Success) vs patients with short fusion and treatment failure (S/Fail). Multivariate analysis and ROC curve assessed demographic, surgical, and radiographic predictors of S/ Fail and L/S Success status. Conditional inference tree (CIT) determined cut-off values for the continuous predictors. Seventy-two cervical deformity patients with CT fusion included (60.3±9.0years, 60% F, 29.4±7.6 kg/m2, levels fused: 7.8±3.2). By approach, 61% posterior-only and 39% combined. Fifty-nine patients (82%) had CT fusions with LIV of T4 or above, while 13 patients (18%) had fusions extending below T4. Thirty-two patients (44.4%) met the optimal outcome criteria, with no difference by fusion length (p=0.171). Eight patients qualified as long fusions with treatment success, while 35 patients were classified as short fusions with treatment failure. Regression analysis identified the predictors of treatment success in patients with fusion construct extending beyond T4: baseline sacral slope ≤33.5° (OR: 15.0), not undergoing high grade (PSO or VCR) osteotomy (OR: 15.0) and being Ames descriptor type C (OR: 13.5); all p<0.05). ROC curve accounting for these factors resulted in an AUC of 82.0%. Regression analysis identified predictors of treatment failure in patients with short fusion construct: levels fused >6 (OR: 4.3), Ames descriptor type CT (OR: 11.5), Ames cSVA modifier grade 1 or 2 at BL (OR: 4.56), and Flatneck Lafage morphotype (OR: 4.5); all p<0.05. Multivariate regression and ROC curve accounting for these factors resulted in an AUC of 84.3%. Treatment success in patients with fusion constructs extending into the thoracic spine vs treatment failure in patients with short fusions may be reliably predicted by the location of the deformity apex, measures of surgical invasiveness, and preoperative deformity severity. Specifically, treatment success in longer fusions is related to deformity apex in the cervical spine and having deformity where adequate correction does not necessitate high grade osteotomy. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Robot-assisted surgical techniques are being increasingly implemented to increase surgeon accuracy and stamina; however, further investigation of the introductory phase of robot technology on surgical outcomes remains warranted. To assess complication rates of robotic surgery in elective spine patients. Retrospective cohort study. A total of 10,501 elective spine patients. intra- and postoperative complication rates; reoperation rate. Patients ≥18 years undergoing elective spine surgery with BL to 2-year follow-up were isolated in a single-center spine database. Patients were grouped by absence or presence of robotic assistance during operation. Univariate analyses identified differences in perioperative outcomes [op time, estimated blood loss, length of stay], rates of intraoperative [durotomy, massive blood loss, neurologic deficit] and postoperative complications [cardiopulmonary, neurologic, GI, GU, infection, mechanical], and reoperation rates by 2Y postop]. Regression analysis assessed the impact of robotic surgery on outcomes. A total of 10,501 patients met inclusion criteria (57years, 49% F, 29.0kg/m2) and underwent elective spine surgery (mean levels fused: 3.0±3.3, EBL: 375mL, op time: 206 min, mean UIV: T9, mean LIV: T12). Of these patients, 424 (4.0%) underwent operation with robotic assistance. Compared to a general cohort of elective spine surgery patients, robotic-assisted surgeries had lower levels fused (1.99 vs 3.07), longer op time (301 vs 202min), and longer LOS (4.2 vs 3.2 days); all p<0.01. Robotic patients were more likely to undergo combined approach (p<0.001). Amongst common primary or concurrent diagnoses of patients undergoing robotic spine surgery, 152 patients (36%) had DDD, 161 patients (38%) HNP, 250 patients (59%) degenerative spondylolisthesis, 287 patients (68%) stenosis, and 228 patients (54%) had radiculopathy. Robotic and non-robotic patients did not differ in terms of functional HRQL outcomes [NDI, EQ5D, NRS Neck, NRS Arm] up to 2-year postop (all p>0.05). Robotic and non-robotic patients did not differ in rates of intraoperative complications, including durotomy, massive blood loss, and delayed extubation (all p>0.05). Robotic patients had higher rates of postop ileus (12% vs 7%, p=0.04), but did not differ in overall postop complications, surgical site infection, cardiopulmonary, mechanical, or neurologic complication. Robotic patients had higher rate of reoperation (6% vs 4%, p=0.004). Regression analysis controlling for revision status, decompression, and approach found that robotic surgery patients had lower odds of delayed extubation (OR: 0.155 p=0.025). Robotic surgery did affect the odds for other complications, including durotomy, neurologic, cardiopulmonary, mechanical, infection, and reoperation (all p>0.05). Robotic and non-robotic procedures for elective spine patients were equally as safe in terms of intraoperative and postoperative complications with equivocal functional outcomes up to 2-years postoperatively. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

PROMIS is a computer based adaptive test. However, there is a lack in research in whether these PROMIS scores translate into clinically relevance and applicability in patients at higher operative risk categories. Assess if the PROMIS metric can be utilized to establish a gradient to evaluate complication occurrence alongside ODI. Retrospective review of a single-center stereo-radiographic database. Patients receiving spinal corrective procedures with complete baseline radiographic and PROMIS data. PROMIS metrics (Pain Intensity, Physical Function, Pain Interference). Surgical patients ≥18 years old with available baseline (BL) radiographic and PROMIS data were isolated in the Quality Database. The relationship between ODI and PROMIS was assessed via linear trends to determine whether the two have discriminative power over each other. The linear trend was mapped between ODI and PROMIS, and patients were divided into quartiles via calculations of perpendicular lines at quartile points to determine whether there was a higher density of complication occurrences at the higher quartile of this association. A total of 231 patients (58.7 years, 49.8% female, 29.3kg/m2, mean Charlson comorbidity score: 1.2) met inclusion criteria. By surgical approach: 74.5% posterior, 11.3% anterior, 14.3% combined; mean levels fused: 1.0±0.1. Of the patients included in the study, 155 had both BL ODI and PROMIS data. There were 65 patients in the upper 50th percentile of both ODI and PROMIS. This quadrant of patients experienced a significantly higher complication rate (24.6%) compared to the remainder 10.1% (p=0.016). A linear relationship for ODI vs PROMIS was established (R2=0.4548). There were 36 patients in the 0-25th percentile, 42 in the 25th-50th, 39 in the 50th-75th and 37 in the 75th-100th. Density of complication occurrence was highest at the highest percentile, as 32.4% of patients in the 75th-100th group experienced a complication compared to 2.8% of the 0-25th, 16.7% of the 25th-50th and 12.8% of 50th-75th. Utilizing both ODI and PROMIS scoring systems can guide proper delineation of patients based on their baseline radiographic severity. Based on the results of our study, it appears that these scoring systems used in conjunction may serve as a more appropriate metric to predict postoperative complications, rather than their independent utility. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Recent studies have suggested that in patients with neck pain, both psychological and physical symptoms need to be addressed. Cognitive behavioral therapy (CBT) works to address risk factors through education about pain, modification of maladaptive beliefs, and increasing patient's self-efficacy. To determine the long-term effectiveness of brief psychological intervention on psychological outcomes in cervical spine surgery. Prospective, blinded, and placebo-controlled trial. Forty-eight patients undergoing cervical spine surgery. Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), visual analog scale (VAS), EuroQol Five Dimensions (EQ5D), Numeric Rating Scale (NRS) for neck and arm pain. To date, 48 patients age >18yrs with symptomatic cervical degenerative disease have been enrolled in the RCT. All patients underwent elective cervical surgery of ≤5 levels, and had an NDI >20%. Patients who met psychological distress criteria [DRAM >17 and <33, FABQ >49 and <66, PCS >30 and <52, or OEQ ≤2] were randomized to a treatment group (CBT or placebo [Sham]). Patients exceeding these criteria were assigned to the DRAM Observational group. The remaining patients were considered controls. CBT and Sham treatment groups each received 6 sessions prior to surgery. The Control and DRAM Observational groups had no intervention prior to surgery. Baseline (BL) to 2-year (2Y) changes in HRQLs were assessed by randomization group. A total of 48 patients enrolled (53.6yrs±10.7yrs, 49% female, 29.6±5.9kg/m2), and underwent surgical correction (levels fused 2.2±1.5, EBL: 111mL, operative time: 177min). By surgical approach, 80% underwent anterior-only, 16% posterior-only, and 4% combined. By randomization group: 17 (35.4%) CBT, 12 (25.0%) Sham, 10 (20.8%) Control, and 9 (18.8%) DRAM. All patients had HRQL data collected preoperatively; 33 patients (68.8%) completed 2Y follow-up. Overall, the following number of patients improved from BL to 2Y in each HRQL: PCS – 21, FABQ – 16, mJOA – 18, NDI – 24, EQ5D – 17, VAS – 21, NRS Neck – 20, NRS Arm – 21 patients. Univariate analysis showed that patients in the CBT group trended toward a higher rate of improvement in PCS (56% vs other groups: 41%, p=0.338), FABQ (50% vs 28%, p=0.133), NDI (69% vs 45%, p=0.124), EQ5D (50% vs 31%, p=0.209), VAS (63% vs 38%, p=0.114), NRS Neck (56% vs 38%, p=0.236), and NRS Back (63% vs 38%, p=0.114). These trends were maintained when comparing the CBT group with each of the Control, Sham, or DRAM Observational groups individually. While limited by sample size, clear trends in our cohort of operative cervical spine patients show that improved psychological and functional outcomes may be achieved with preoperative CBT intervention. Further investigation is warranted to validate these findings. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Adult spinal deformity is associated with severe pain and disability. Recent literature has shown that surgical intervention can significantly improve patients' quality of life and lessen disease burden. As many patients requiring spine surgery are elderly and often frail, restoration of alignment targets may differ. The literature is scarce on how different frailty states affect realignment goals. Modify the age-adjusted alignment goals using the Frailty Index to optimize outcomes in surgical adult spinal deformity (ASD) patients. Retrospective cohort study of a prospective multicenter database of ASD patients. This study included 245 ASD patients. Complications, HRQLs (SRS-22, ODI, SF-36). Operative ASD patients (scoliosis ≥20°, SVA ≥5cm, PT ≥25°, or TK ≥60°) with available baseline and 2-year radiographic and HRQL data were included. ASD frailty index was used to stratify patients into not frail (NF) and frail (F) categories. Linear regression analysis established normative radiographic thresholds, utilizing previously published age specific US-Normative ODI values (Lafage et al) and the frailty index, based on a cohort of patients with an ideal clinical outcome (no major complications, no PJK, and an SRS-satisfaction of >4). Patients were considered "matched" if 2-year postop alignment was within 1 standard deviation (+1SD overcorrected-1SD undercorrected). A total of 245 patients included (57±15yrs, 82% female, 26±5.14kg/m2, ASD-FI: 2.9±1.6, CCI: 1.8 ±1.7). Patients had a mean level fused of 11.1±4.4, LOS of 7.7 days±4.4, EBL of 1577 mL, operative time of 377 min, with 63% undergoing an osteotomy. In terms of surgical approach, 69.9% posterior-only, and 29.3% had a combined approach. Primary analyses demonstrated correlation between baseline frailty index, PT, PI-LL, SVA, and ODI, (p<0.05). Linear regression analysis developed age and frailty adjusted alignment threshold. Thresholds for correction were found to increase with age, as previously determined by Lafage et al, as well as, increase with a higher frailty index. Frail patients, corresponding to the same age, were found on average to have a higher alignment threshold than not frail patients in SVA, PI-LL, and PT. Controlling for age, CCI, and baseline deformity, frail patients experienced less overall PJK when undercorrected in PI-LL in the Lafage Schwab age-adjusted parameters (.28[.09-.85], p=.024). Patients who achieved a match in the newly developed age and frailty-adjusted parameters in PI-LL had lower rates of PJF (5% vs 15%, p=.014 with improved HRQLs, and those matched in SVA had improved HRQLs when compared to those who were under- or overcorrected. Matched SVA patients had a shorter LOS. Age-adjusted alignment by Lafage et al was the first study to recognize that older age warrants a lower degree of correction, and, the original SRS-Schwab criteria was modified accordingly. Alignment targets accounting for both frailty and age were developed with larger thresholds for increasing frailty. In this study, we found patients who were matched in these age and frailty adjusted thresholds had lower rates of PJF and significantly improved HRQL outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Cervical deformity (CD) corrective procedures are ever-evolving, along with the field of spine surgery. The goal of this study was to examine whether surgical advancements over the years have improved or changed outcomes, and the overall way in which we approach CD surgery. To investigate if operative approach and outcomes of CD have changed over time in respect to surgical advancements. Retrospective cohort study of a prospective cervical deformity database. A total of 123 CD patients (≥18 years) with complete BL and 2Y HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were stratified into 2 groups based on DOS: early (Group I-2012-2014) and later (Group II-2015-2019). Osteotomies were grouped using grading by Ames et al. into low grade (LGO): Grade 1 & 2, and high grade (HGO): Grade 6 & 7. UVA and MVA analyzed differences in osteotomy usage and radiographic, surgical and clinical parameters. Significant CD was characterized by extension XR TS-CL >17°. Rigid deformity was defined by a change of <10°difference between flexion and extension XR. Complications, HRQL (NDI, mJOA, EQ5D). CD patients (≥18 years) with complete BL and 2-year HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were stratified into 2 groups based on DOS: early (Group I-2012-2014) and later (Group II-2015-2019). Osteotomies were grouped using grading by Ames et al. into low grade (LGO): Grade 1 & 2, and high grade (HGO): Grade 6 & 7. UVA and MVA analyzed differences in osteotomy usage and radiographic, surgical and clinical parameters. Significant CD was characterized by extension XR TS-CL >17°. Rigid deformity was defined by a change of <10°difference between flexion and extension XR. There were 123 CD patients that met inclusion criteria (61years, 63%F, 29.0kg/m2, CCI: 1±1.4). Radiographically at baseline, patients presented with: PT: 19.6± 11°; PI: 55±13°; PI-LL:.9±17.4°; SVA:-3±68mm, TS-CL: 39 ±21°; cSVA: 45±26. Surgical details were 7.7± 4 levels fused with a mean EBL of 1031mL. By surgical approach, 46% had a posterior approach, 20% anterior, and 37% combined. Group I had 49 patients, and Group II had 74. Group II had a higher CCI (1.1 vs.8, p=.2) while there were no significant differences in number of levels fused, reoperations, DJK development, or HRQL metrics between groups (p>0.05). Overall, 53% of patients had an osteotomy. Patients in Group II had a lower usage of HGO (9% vs 23%, p<0.05). In patients with significant CD, Group II received less HGO (3% vs 33%, p<0.05). In posterior approaches, controlling for age, BL deformity, and CCI, Group II underwent less HGO.32[.08-1.2] p=.1. Controlling for age, CCI, and BL deformity, Group II had lower usage of HGO in rigid deformity (.197[.04-.97], p<0.05). Overtime, patients undergoing cervical deformity surgery received less high-grade osteotomies, even with high grade deformities. Despite operating on a cohort with a greater degree of comorbidity, there was no deterioration in clinical and radiographic outcomes. These findings reflect a better understanding of surgical management and the utility of invasive osteotomies in adult cervical deformity. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Increasing pelvic tilt (PT) is a primary compensatory mechanism in adult spinal deformity (ASD). By SRS-Schwab criteria, PT >20° is considered pathologic. Some ASD patients improve their PT following ASD correction, while others do not. The driving forces behind this lack of PT-response are not well defined. To determine the perioperative characteristics associated with PT normalization after ASD corrective surgery. Retrospective cohort study. A total of 176 ASD patients. Patient profile, radiographic parameters, and surgical factors associated with PT normalization. Operative ASD patients fused to S1/pelvis with full preoperative data as well as preoperative (BL), 6-week (6W), 1-year (1Y), and 2-year (2Y) postop PT measurements were included. PT normalization was assessed at 6W and 2-year follow-up. Univariate analyses were used to compare normalized (PTNorm) and non-normalized (NON) patients in terms of demographics, surgical and radiographic descriptors, postoperative alignment, and clinical outcomes. Multivariate regression and ROC curve assessed periop factors predicting 6W PT normalization. Conditional inference tree (CIT) determined thresholds for the continuous variables identified as independent predictors of PT normalization. There were 176 ASD patients that met inclusion criteria (62.9±10.2years, 80%F, BMI 26.9±4.9 kg/m2, CCI: 1.88), and underwent surgery (levels fused 12.1±3.9, EBL: 1955mL, op time: 402min). At each time point, mean PT was as follows: BL: 25.7º, 6-week: 19.0º, 1-year: 21.2º, and 2-year: 22.3°. Patients classified as having normal PT by SRS-Schwab criteria (PT<20º): BL: 27.8%(n=49), 6W: 52.3%, 1-year: 47.2%, 2-year: 40.9%. Of the 127 patients with non-normal PT at BL, 50 (39.4%) normalized postoperatively by 6 weeks. Few patients normalized in PT after the 6-week mark: 7 by 1-year and another 2 by 2-year postop for a total of 37 2-year PTNorm patients. Sixteen patients with non-normal PT at BL normalized by 6W, but reverted at 2-year. Both 6 weeks and 2 years PTNorm patients had higher levels fused than NON patients (both p<0.05). 6W PTNorm patients were more likely to undergo combined approach(p=0.005). Two-year PTNorm patients were more likely to have undergone VCR(p=0.011). Normalized and non-normalized patients did not differ in BL SRS-Schwab PI-LL and SVA or in GAP proportionality (all p>0.05). Six weeks PTNorm patients were more likely to be overcorrected in PT, PI-LL, and SVA compared to NON patients at 6 weeks postop (all p<0.05). The same held true for 2-year PTNorm patients and 2-year radiographic alignment. Compared to non-normalized patients, both 6 weeks PTNorm patients and 2-year PTNorm patients had lower rates of implant failure and rod fracture (all p<0.05). 6W PTNorm patients had a lower revision rate(p=0.018). Binary logistic regression with CIT identified independent predictors of PT normalization by 6 weeks: undergoing combined approach, UIV at or above T8, levels fused >10, invasiveness score >109, baseline cSVA<41.5°, 6 weeks PI-LL diff ≥21.0°, 6 weeks sacral slope diff ≥7.9°, 6 weeks PT diff ≥7.5°; all p<0.05. Validation of a predictive model for 6 weeks normalized vs non-normalized patients including these factors yielded an AUC of 85.2%. PT normalization following ASD correction occurred in almost 40% of patients by 6 weeks postop. Normalization is more likely to occur in patients where reconstruction addresses lumbopelvic mismatch, extends above the apex of the thoracic kyphosis, and has adequate surgical invasiveness to achieve full alignment correction. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical correction of cervical deformity (CD) has been associated with superior alignment and functional outcomes. It has not yet been determined whether baseline and postoperative T1 slope and C2 slope correlate with health-related quality of life (HRQL) metrics and radiographic complication. To determine the impact of T1S and C2S deformity severity on HRQL metrics and DJK development in operative cervical deformity patients. Retrospective cohort study. A total of 119 CD patients. Radiographic parameters; HRQLs. Included: Operative CD patients with UIV above C7 and with pre-(BL) and up to 2-year (2Y) postop radiographic/HRQL data. Cervical deformity was defined as meeting at least one of the following radiographic parameters: C2-C7 lordosis < -15°, TS-CL >35°, segmental cervical kyphosis >15° across any 3 vertebra between C2-T1, C2-C7 SVA >4cm, McGregor's slope >20°, or CBVA > 25°. Spearman's rank-order correlation and linear regression analysis assessed the impact of baseline T1 slope (T1S) and C2 slope (C2S) on baseline HRQL metrics (NDI, mJOA, EQ5D, NRS Neck, NRS Back), and the impact of postoperative T1S and C2S on follow-up HRQLs. Logistic regression and conditional inference tree (CIT) machine learning were used to determine baseline radiographic thresholds for improving in ≥2 HRQL metrics from BL to 2Y, and 2Y radiographic thresholds for developing DJK or DJF by 2Y postop. A total of 119 CD patients met inclusion criteria (61.2±10.5years, 63%F, BMI 29.0±7.5kg/m2, CCI: 1.00±1.31) and underwent surgery (levels fused 7.5±3.7, EBL 990mL, op time 547min). By approach, 19.3% anterior-only, 44.5% posterior-only, and 36.1% combined. Mean BL radiographic parameters: PT 19.6°, PI-LL 1.4°, SVA 1.9mm, T2-T12 kyphosis -46.8°, C2-C7 lordosis -9.0°, T1S 29.0°, TS-CL 38.2°, C2S 37.7°, cSVA 44.0mm, and C2-T3 -18.0°. Mean BL HRQLs were as follows: NRS back 5.0, NRS neck 6.7, NDI 47.9, mJOA 13.5, and EQ5D 0.74. Spearman correlation and linear regression identified no association between baseline T1S or C2S and HRQL metrics, or between 2Y postop T1S and HRQLs (all p>0.05). Correlation and linear regression found significant associations of higher C2S with higher NDI (p=0.042), lower mJOA (p=0.011), and lower EQ5D (p=0.009), all indicating higher degree of disability at 2Y postop. Logistic regression with CIT identified thresholds for improving in 2 or more HRQL metrics by 2Y postop: baseline T1S < 32.8° (OR: 2.47) and C2S <46.7° (OR: 2.40); both p<0.05. Regression and CIT also identified postoperative radiographic thresholds for developing DJK or DJF by 2Y: T1S >45.3° (OR: 16.0) and C2S >32.5° (OR: 6.07); both p<0.05. Baseline deformity severity in terms of T1 slope and C2 slope can be predictive of postoperative functional outcomes in cervical deformity patients, while postoperative deformity in T1S and C2S can be predictive of DJK and DJF occurrence. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

With health care costs on the rise, hospitals have increasingly focused on providing economically efficient medical services. Adult spinal deformity surgery remains an expensive medical intervention with high risk for complications and revisions, especially following mechanical failure in the context of proximal junctional kyphosis (PJK). We sought to evaluate the impact of PJK on associated expenditures following an index surgery for ASD. To evaluate the effect of proximal junctional kyphosis on the cost effectiveness of corrective adult deformity surgery. Retrospective cohort study of a prospective single-center database of ASD patients. A total of 147 Adult Spinal Deformity Patients. Complications, HRQLs (Oswentry Disability Index [ODI]), Quality adjusted life years (QALY). Adult Spinal deformity patients with 2-year HRQL follow-up were included. Utility data was calculated using published conversion methods to convert ODI to SF-6D. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications and comorbidities classified according to CMS standard definitions. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, reoperations and revisions. After accounting for all postoperative events, including mortality, cost per QALY by 2Y was calculated for revisions that occurred due to proximal junctional kyphosis. A total of 147 adult spinal deformity patients met inclusion criteria (55.22years, 54% Female). At baseline, patients presented radiographically as: Pelvic Tilt (23.66±11.7), Pelvic Incidence- Lumbar Lordosis (-2.9±12.6), Sagittal Vertical Axis (60.5±76.8), T1 Pelvic Angle (22.6±14.3). Surgical details: EBL of 1823 mL, operative time of 327 min, with.4% undergoing an anterior approach, 90.2% posterior-only approach, and 9.3% combined approach. Overall, 54.3% of patients developed PJK within 2 years postoperatively, with 22% undergoing reoperation for PJK. Average cost of revision surgery due to PJK was $93,688 ± $21,467. The cost for PJK patients, including the cost associated with their revision surgery, was higher ($103,760 vs $71,000). Baseline ODI (39 vs 32) and 2Y ODI (39 vs 27) were higher for PJK patients, however, PJK patients did improve to a greater degree (-12 vs -10). The overall cost per QALY by 2Y was higher for PJK patients ($116,170 vs $95,347). Patients that developed PJK had an almost $30,000 higher initial cost at 2 years. When looking at the cost per quality adjusted life years by 2Y, PJK resulted in slightly more than $20,000 in cost. These findings suggest prophylactic measures to mitigate PJK may improve the cost utility of adult spinal deformity surgery and can help policy efforts for adequate resource allocation for these complex patients. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Frailty status has often been identified as a determining factor for outcomes after adult spinal deformity (ASD) corrective surgery and may result in a ceiling regarding the best possible outcome Identify cohorts of patients with low complication rates by frailty status and determine the duration of time they maintain a good surgical outcome. Retrospective cohort study of a prospectively enrolled ASD database. This study included 224 ASD patients. Major complications, reoperations, patient-reported outcome measures (Oswestry Disability Index) ASD patients with frailty measures, baseline (BL) and 2-year (2Y) ODI were included. Miller et al thresholds: Not Frail (NF) < 0.3; 0.3 < Frail (F) < 0.5; Severely Frail (SF) > 0.5. ANCOVA found estimated marginal means adjusting for age, invasiveness, and BL Sacral Slope, Pelvic Tilt, Pelvic Incidence, PI-LL, and SVA. Kaplan-Meier curve estimated time until major complication or reoperation. Linear regression analyzed ODI change between 1Y and 2Y. Reduction in ODI between 1Y and 2Y of 5+ points was improvement, within ±5 points maintenance, increasing by 5+ points deterioration. Minimum clinically important differences (MCID) for ODI at 2Y were also assessed. Of 224 patients, 54.9% NF, 29.9% F, and 15.2% SF, difference in ODI from BL to 2Y in the most improved quartile (HIGHEST) by frailty group: NF: -4.51; F: -12.3; SF: -66.3 (p<0.001). SF HIGHEST major complication rate: 58.3%, F HIGHEST 29.4%, NF HIGHEST 41.8%. At 1Y, the quartile of NF with the lowest ODI had a mean score of 2.28, F 8.98, and SF 9.66 (p<0.001). Fewer SF patients did not experience any complications and had 2Y PI-LL < 10 (6.4%) compared to F (11.6%) and NF (16.0%) (p=0.002). NF had the least deterioration (16.3%, F: 29.8%, SF: 30.6%, p=0.099); however, groups were not significantly different in improvement (NF: 37.6%, F: 30.6%, SF: 36.6%, p=0.656). Higher 1Y ODI had greater odds of improvement (1.823 [1.667-1.978], p<0.001). KM curve revealed that NF had longer estimated time before complication or reoperation (7.8 years) compared to F (6.3 years) and SF (3.9 years) (p=0.001). Severely frail patients had the lowest estimated time before a major complication or reoperation. Frail patients had the best maintenance of ODI score between 1 and 2 years. Severe frailty may limit improvement, and improving to a lower ODI score is more difficult to maintain over the course of a year. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical intervention aimed at addressing adult cervical deformity (ACD) is an invasive and complex procedure that surgeons often elect to perform on different days. Despite patients undergoing staged procedures being older, with more comorbidities, staged patients had superior short- and long-term outcomes while undergoing less osteotomies, possibly leading to the overall decrease in complications. To determine differences in outcomes between staged vs same-day procedures. Retrospective cohort study of single-center database. A total of 65 CD patients. Complications; radiographic parameters; HRQL metrics (Neck Disability Index [NDI], EQ5D, mJOA, Numerical Rating Score [NRS] neck and back pain). Inclusion criteria: operative CD patients (cervical kyphosis>10°, with cSVA>4cm or CBVA>25°) and >18yrs undergoing either staged or same-day procedures. Significant differences in surgical, radiographic and clinical factors and outcomes were determined. A total of 65 CD patients met inclusion criteria (58.3 years, 46% Female, 28.3 kg/m2). Overall, 32 (48%) of these patients underwent staged procedures, while 33 (52%) underwent a same-day combined approach. Staged patients were older (61 vs 56, p=.03) and had a higher CCI (1 vs.63, p=.13). Patients that had a staged procedure experienced fewer overall complications (22% vs 43%, p=.002) and less neurological complications (p<0.05). Staged patients had an overall lower usage of osteotomies (25% vs 53%, p=.02). Staged patients had a lower 6W NDI score (47 vs 56, p=.16), lower 3M NSR Neck (5.5 vs 6.6) and Back pain score (5.2 vs 5.9), lower 6M NSR Neck (3.5 vs 5.2), back pain score (3.4 vs 5.6) and NDI score (30 vs 40). At 2-years follow-up, staged patients had a lower NSR neck (3.6 vs 6.2), back pain score (4.4 vs 7.4), NDI score (28 vs 43, all p<0.05) and higher mJOA/SWAL scores. Staged procedures have become more prevalent as surgeons aim to decrease perioperative adverse events and improve patient outcomes. Despite patients undergoing staged procedures being older, with more comorbidities, staged patients had superior short- and long-term outcomes while undergoing less osteotomies, possibly leading to the overall decrease in complications. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Frailty is a dynamic measure of physiological age that is a strong predictor of a patient's surgical risk. The purpose of this study is to investigate the impact of frailty on the perioperative outcomes and costs associated with operating on frail ASD patients. To investigate impact of frailty on operative course, clinical outcomes, and cost utility. Retrospective cohort study of prospective, multicenter ASD database. A total of 245 ASD patients were included. Complications; health-related quality of life (HRQL) : ODI. Operative ASD patients (scoliosis >20, SVA>5cm, PT>25, or TK>60) with available baseline (BL) and 2-year (2Y) radiographic and HRQL data were included. The ISSG frailty index was used to stratify patients into 2 categories : not frail (NF) (<3) and frail (F) (>3). Univariate and multivariate analysis assessed differences in radiographic, surgical, and clinical factors. IHS-adjusted ODI and SRS compared recovery periods between F/NF patients. Cost utility using published methods convert ODI to SF-6D obtained Quality Adjusted Life Years (QALY). QALYs utilized a 3% discount rate for residual decline to life expectancy (78.7 years). Direct costs calculated using the PearlDiver database incorporating complications, LOS and associated health care costs. A total of 245 ASD patients met inclusion criteria (57yrs±15.0, 82%F, BMI : 26.3 kg/m2 ±6.0, ASD-FI : 2.9±1.6, CCI : 1.55 ±1.7). Surgical patients had a mean number of levels fused of 11.4±4, LOS of 7.7 days±4.4, EBL of 1686 mL, operative time of 374 min, with 70% undergoing an osteotomy. In terms of surgical approach, 76% were posterior-only, and 23.6% had a combined approach. Frailty breakdown was: 138 (55%) NF and 107 (45%) F patients. F patients had higher mean PT (25 vs 20), PILL (21 vs 10), TK T4-T12 (-33 vs -36), SVA C7-S1 (80 vs 35), and a higher BL ODI (52 vs 27, all p <0.05). F patients had a higher level of invasiveness (99 vs 88), greater EBL (2058 vs 1560) and a longer LOS (8.6 vs 7, all p<0.05), as well as more overall complications (86% vs 78%, p=.094), more major complications (41% vs 24%, p=.003) and more reoperations (24% vs 18%, p=.314). Improvement in ODI was greater for frail patients (-19 vs -12); however, at 2Y ODI remained significantly higher (32 vs 15, both p<0.05). F patients had a higher IHS-adjusted ODI (32 vs 15, p<0.05). In a cost analysis, 2Y cost of F patients was higher ($90,967 vs $81,479); however, due to a greater gain in QALY, cost per QALY at life expectancy was comparable to NF patients ($71,600 vs $75,191). Frail patients experienced a longer LOS and higher EBL, possibly due to the increased invasiveness used to treat a more severe deformity with a worse preoperative physiological state. Although frail patients experienced more complications, the higher overall improvement in ODI contributed to a comparable cost utility despite a higher initial cost. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]