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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]

• Improvements in radiographic Ames modifier grades correlate with better clinical outcomes and spinal alignment. • Deformity descriptors have differential responses to modifier improvements. • The Ames-ACD classification may apply to cervical deformity patients' postoperative alignment and outcomes. This retrospective cohort study describes adult cervical deformity(ACD) patients with Ames-ACD classification at baseline(BL) and 1-year post-operatively and assesses the relationship of improvement in Ames modifiers with clinical outcomes. Patients ≥ 18yrs with BL and post-op(1-year) radiographs were included. Patients were categorized with Ames classification by primary deformity descriptors (C = cervical; CT = cervicothoracic junction; T = thoracic; S = coronal) and alignment/myelopathy modifiers(C2-C7 Sagittal Vertical Axis[cSVA], T1 Slope-Cervical Lordosis[TS-CL], Horizontal Gaze[Horiz], mJOA). Univariate analysis evaluated demographics, clinical intervention, and Ames deformity descriptor. Patients were evaluated for radiographic improvement by Ames classification and reaching Minimal Clinically Important Differences(MCID) for mJOA, Neck Disability Index(NDI), and EuroQuol-5D(EQ5D). A total of 73 patients were categorized: C = 41(56.2%), CT = 18(24.7%), T = 9(12.3%), S = 5(6.8%). By Ames modifier 1-year improvement, 13(17.8%) improved in mJOA, 26(35.6%) in cSVA grade, 19(26.0%) in Horiz, and 15(20.5%) in TS-CL. The overall proportion of patients without severe Ames modifier grades at 1-year was as follows: 100% cSVA, 27.4% TS-CL, 67.1% Horiz, 69.9% mJOA. 1-year post-operatively, severe myelopathy(mJOA = 3) prevalence differed between Ames-ACD descriptors (C = 26.3%, CT = 15.4%, T = 0.0%, S = 0.0%, p = 0.033). Improvement in mJOA modifier correlated with reaching 1-year NDI MCID in the overall cohort (r = 0.354,p = 0.002). For C descriptors, cSVA improvement correlated with reaching 1-year NDI MCID (r = 0.387,p = 0.016). Improvement in more than one radiographic Ames modifier correlated with reaching 1-year mJOA MCID (r = 0.344,p = 0.003) and with reaching more than one MCID for mJOA, NDI, and EQ-5D (r = 0.272,p = 0.020). In conclusion, improvements in radiographic Ames modifier grades correlated with improvement in 1-year postoperative clinical outcomes. Although limited in scope, this analysis suggests the Ames-ACD classification may describe cervical deformity patients' alignment and outcomes at 1-year. [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]

Global spinal malalignment plays a vital role in cervical spinal deformity corrective surgery outcomes; however, the literature is scarce on the effects that the individual sagittal parameters have on outcomes. To investigate the impact of sagittal malalignment on cervical deformity patient outcomes. Retrospective cohort study of single-center database. This study included 123 CD patients. Complications; radiographic parameters; HRQL metrics (NDI, EQ5D, mJOA, NRS Neck) Inclusion criteria: operative CD patients (cervical kyphosis >10°, with cSVA >4cm or CBVA >25°) and >18yrs with up to 2Y radiographic and HRQL follow-up. Significant differences in surgical, radiographic, and clinical factors and outcomes were determined. Deformity in PT, SVA, and PILL was defined using the SRS-Schwab criteria. "Unmatched" refers to patients who were under corrected or over corrected according to the Schwab age-adjusted parameters (Lafage et al.). A total of 123 CD patients met inclusion criteria (58.3 yrs, 46% Female, 28.3 kg/m2). Overall, 27 (24%) of these patients developed DJK. At baseline, patients presented with the following radiographic profile: PT (18.3), PILL (-.65), SVA C7-S1 (-6.54), cSVA C2-C7 (23.5), and TS-CL (25.2). Patients with DJK had a higher L1-S1 (34 vs 9.2) and T12-S1 (57 vs 35, both p<0.05) and trended towards a higher cSVA (-11.7 vs -3.7), C2-T3 (57.6 vs 37.4), and C2-S1 (17 vs 5.9, p>0.05). Patients with a deformity in PT at baseline developed more DJK by 2 years (26% vs 11%), had more DJF (7% vs 2%) and a higher NDI and NSR back pain. Patients with mismatch at baseline had higher rates of DJK (30% vs 22%), and patients with SVA deformity at baseline had a lower mJOA, SWAL Food selection, SWAL Communication, and a higher EQ5D. Patients with a mismatched alignment in Roussouly preoperatively had higher rates of DJK at 3M (18% vs 12%), 6M (26% vs 16%), 1Y (24% vs 14%), and 2Y (26% vs 13%, all p<0.05). Patients who were unmatched in SVA by 2Y had higher rates of DJK development at 2Y (25% vs 6%), and those unmatched in PILL by 2Y had higher rates of 2-year DJK (31% vs 19%) and higher 2-year NDI (38 vs 31). Patients who had a mismatch in Roussouly postoperatively had higher rates of DJK by 2 years (33% vs 23%, allp<0.05). Global spinal malalignments play an important role in the outcomes of cervical spinal deformity corrective surgery. The presence of abnormal global sagittal malignment at baseline is associated with higher rates of DJK development and worse clinical outcomes, while patients who maintained poor sagittal alignment up to 2Y were associated with significantly greater development of DJK and inferior neck disability index scores. 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]

Robot-assisted surgical techniques are increasingly implemented to increase surgeon accuracy and stamina; however, the effects of surgeon learning curve on outcomes have not been well studied. Identify differences in outcomes and complication rates between robot-assisted and unassisted lumbar interbody fusions, and determine the presence of a learning curve with regard to surgeon case load. Retrospective review of a single-center stereographic database. This study included 581 robotic assisted surgical patients. Perioperative outcomes (estimated blood loss [EBL], length of stay [LOS]), postoperative complication rates, return to OR (30 days). Robotic cases were isolated from a single center multisurgeon database. Surgeons' cases were ranked by date of surgery into 3 quartiles: 1st quartile 2018 (Early) was analyzed against the 3rd quartile 2020 (Late). Univariate analysis was used to assess differences between quartiles. A propensity score matched (PSM) cohort of patients undergoing identical surgical procedures without robotic assistance was included as a control group and compared to both Early and Late groups. A total of 281 patients undergoing robotic surgery met inclusion criteria (age: 56±12.5, BMI: 30±6, 42% female) with an average of 1.6 levels fused. Early group had 95 patients and Late group had 94. Late group had a lower EBL (314 vs 492, p<0.05), shorter LOS (3.8 vs 4.7, p=.1), greater amount of levels fused (2 vs 1.4, p=.021), greater amount of decompressions (2.5 vs 1, p=.003), with less return to the OR within 30 days (7% vs 14%, p=.2), and a lower rate of overall postoperative complications (34% vs 54%, p=.04). In the control group, the mean EBL was 390±790, LOS 3.7±2.7, overall postoperative complication rate 58%, and rate to return to OR within 30 days was 8%. When the control cohort was compared to the Early robotic cohort, the robotic cohort had a higher EBL (492ml vs 390ml, p<0.05), greater LOS (4.7 vs 3.7 days, p<0.05), greater return to OR within 30 days (14% vs 8%, p=.1), and a comparable overall rate of complications (54% vs 58%, p>0.05). When the control cohort was compared to the Late robotic cohort, the robotic cohort had a lower EBL (314ml vs 390ml, p=.1), comparable LOS (3.7 vs 3.8 days, p>0.05), similar return to OR within 30 days (7% vs 8%, p>0.05), and a lower overall rate of complications (34% vs 58%, p=.02). In this study, perioperative outcomes improved drastically in the later cohort. When compared to an identical control cohort, early robotic cases had worse perioperative outcomes. However, when the later robotics cases were compared to the control cohort, robotic-assisted procedures demonstrate superior clinical outcomes. These findings suggest despite the initial worse outcomes of robotic surgery it proves to be an increasingly viable option for adult spinal deformity surgery. 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]

Surgical correction of adult spinal deformity (ASD) has been associated with superior alignment and functional outcomes. However, postoperative complication rates remain relatively high. The extent to which potentially modifiable patient-related factors can influence complication rates in adult spinal deformity patients has not been effectively evaluated. Evaluate the association between modifiable patient-related factors on complications following ASD corrective surgery. Retrospective. A total of 689 ASD patients. Complication and reoperation rates. ASD patients with 2-year (2Y) data were included. Complication groups were defined as follows: 1) any complication; 2) major; 3) medical (cardiac event, ileus, etc.); surgical (site infection, wound dehiscence, etc.); 5) major mechanical (implant failure, rod fracture); 6) major radiographic (PJF [proximal junctional failure], pseudarthrosis, adjacent segment disease); and 7) reoperation. Modifiable risk factors included current smoker, obesity (BMI >30kg/m2), osteoporosis, alcohol use, depression (BL SF-36 MCS <35, perMatcham), psychiatric diagnosis and hypertension. Patients were stratified by BL deformity severity in T1PA (LowDef/HighDef) and age above or below 65 (Young/Older). Means comparison tests assessed prevalence of modifiable risk factors present in those developing specified complications. Binary logistic regression analysis was used to adjust for confounders. A total of 480 ASD patients met inclusion criteria (age 59±15 yrs, 77%F, BMI 27±5 kg/m2, CCI: 1.7±1.7). By 2Y, comp rates: 72% one complication, 28% major, 21% medical, 27% surgical, 11% major radiographic, and 8% had a major mechanical complication. A total of 106 patients (22%) required reoperation. Overall, 318 patients (66%) had at least one of the preoperative risk factors. Age-Deformity Groups: 32% Young LowDef, 19% Young HighDef, 18% Older LowDef, 31% Older HighDef. Within Young LowDef, patients with osteoporosis were more likely to suffer either a major mechanical or radiographic comp (both OR >6, p<.05), although this trend was not seen in the overall cohort. Young HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR: 2.8, [1.04-8.6]; p=.045), while patients with depression or a psychiatric diagnosis suffered major radiographic comps and underwent reoperation more often. Older patients with HighDef developed significantly more complications when diagnosed with depression, including major radiographic comps (23% vs 8%, OR: 3.5, [1.1-10.6]; p=.03). Overall, when controlling for baseline deformity, frailty, and osteoporosis, a diagnosis of depression proved to be a significant risk factor for development of major radiographic complications (OR: 2.4, [1.3-4.5]; p=.005). Certain modifiable patient-related factors, especially mental health status, are associated with increased risk for complications following spinal deformity surgery. Therefore, with consideration to clinical presentation, elaborate on the utility in medical intervention prior to undergoing spinal deformity corrective surgery. 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]

Patients receiving surgery for adult spinal deformity (ASD) are often frail and may be at risk of adverse events following these intensive procedures, including proximal junctional failure (PJF). The role of physiologic age in prognosticating this outcome is not well define To determine if the benefits of optimal realignment on PJF development can be negated by increasing frailty as determined by physiologic age. Retrospective cohort study of prospective, multicenter ASD database A total of 245 ASD patients. Complications. Complications A total of 245ASD 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 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. Of the 245 patients, 138 (55%) of patients were characterized as not frail, 107 (43%) as frail. Overall rate for PJK was 49%, and 12% for PJF. The presence of PJF in the NF group was lower than in the F group, (7% vs 18%; p<0.05). Controlling for age, BL deformity and surgical invasiveness, a higher BL frailty index was correlated with increased odds of developing PJF (OR: 1.4, 95% CI: 1.01-1.9) and the risk of developing PJF for F vs NF patients was 3x higher (OR: 3 95% CI: 1.3-7). Controlling for BL deformity and invasiveness, patients matched in SVA still developed PJF with a high frailty index (OR: 1.7, 95% CI: 1.02-2.8, p=.014). CIT found patients with a frailty index greater than 3.4 had a 2.5x higher likelihood of developing PJF (OR: 2.5, 95% CI: 1.14-5.5, p=.026) and, in a cohort of patients matched in SVA, a frailty index higher than 4.9 led to a 5x higher likelihood of developing PJF (OR: 5, CI: 1.2-20, both p<0.05) Frailty is a significant independent predictor of PJF development, and while optimizing realignment may minimize this effect, frailty still remains a risk factor. The alarmingly high rates of PJF despite adequate alignment in frail patients warrants further research to determine whether operating on very frail patients with large deformity is advisable. 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]

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]

Improvement capability increases with frailty and deformity severity to a certain point. The present study aimed to identify the range in which a patient would benefit from intervention and what the upper limit for reduced improvement would be due to severe frailty or deformity. Investigate whether there is a range of frailty and radiographic measures at which patients improve in their reported outcomes the most after adult spinal deformity corrective surgery. Retrospective. A total of 250 adult spinal deformity (ASD) patients. Major complications, Oswestry Disability Index (ODI). Surgically eligible ASD patients with baseline (BL) and up to 2-year (2Y) ODI were included. Difference between BL and 1Y ODI was calculated, graphed alongside Frailty Index and radiographic measures (sacral slope, pelvic incidence, PI-LL, thoracic kyphosis), and fitted to a polynomial, the vertex representing the value at which patients most improved. Optimal ranges (OR) for these criteria were determined to be within a range of the vertex value. ANCOVA established estimated marginal means while adjusting for covariates including age, sex, and surgical invasiveness. Overall, 250 patients (57.0 years, 81.6% female, 26.3kg/m2) were included. BL Frailty value for vertex of polynomial between BL to 1Y ODI improvement and BL Frailty (R2=0.1199): 5.0. Frailty OR patients (between 4.0 and 5.2) had the highest improvement in ODI at 1Y (-20.44) compared to under the OR (-10.33) and over (-17.37, p=0.001). ODI improvement at 2Y: OR=-20.84; under=-12.32; over=-19.31, (p=0.006). Frailty OR had more improved SRS-22 Total Scores at 1Y (1.12; 0.73; 0.98; p=0.001) and 2Y (1.09; 0.77; 1.02; p=0.013). Radiographic vertices: SS=12.14; PI=53.2; PI-LL=53.1; TK=1.36. Patients who were within ±5 (OR) had greater improvement in 1Y ODI (-15.68) compared to no ORs (-11.27; p=0.125). Patients who met ORs for both frailty and at least one radiographic measure had greatest improvement in ODI by 1Y (p=0.017) and 2Y (p=0.068) and lowest rates of major complications (p=0.086) compared to patients who were under or over the frailty OR and/or did not meet at least one radiographic OR. Patients above the determined thresholds have reduced improvement in patient-reported outcomes despite having more "room to improve," indicating that although capacity to improve is present, frailty or deformity inhibits the ability to do so. 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]

Adult spinal deformity (ASD) and cervical deformity (CD) surgery has seen great improvements in increasing perioperative patient safety and decreasing patient mortality. Previous studies have also demonstrated relatively higher risk of death in cervical deformity surgeries, yet there remains a paucity of literature comparing and contrasting the comorbidities and predictive factors associated with death in ASD versus CD surgery. To assess morbidity and mortality rates and potential correlations with frailty in ASD vs CD patients. Retrospective review of prospective cervical deformity (CD) and adult spinal deformity (ASD) databases. There were 689 ASD patients, 290 CD patients: 979 total. Demographic factors; baseline comorbidities; intra/postoperative complications; mortality. Operative CD patients 18yrs with pre-(BL) and up to 5-year (5Y) postoperative radiographic/HRQL data were assessed. Differences in demographics, radiographic alignment, and complication rates were assessed via means comparison analyses. Conditional backstep binary logistic regression analysis identified predictive factors for mortality. Kaplan-Meier curves assessed survivorship of expired patients. Cox regression assessed survivability adjusting for BL frailty status. Logrank analysis determined differences in the survival distribution between ASD and CD patients. A total of 625 patients met inclusion criteria (417 ASD, 208 CD). Within 5Y, 12 ASD patients (2.88% of ASD cohort) and 16 CD patients (7.69% of CD cohort) expired (p=.004). At baseline, ASD and CD patients differed significantly in BL Frailty score (0.29 vs 0.41, p.05). No significant differences were noted in BL disability per EQ5D-VAS (p>.05). In terms of baseline self-reported comorbidities in expired patients, the three most common for ASD patients were: arthritis (46%), hypertension (31%) and anemia (23%). In CD patients, the three most common comorbid conditions were: osteoporosis (50%), previous myocardial infarction (17%) and any cancer (17%). Complications analysis revealed no significant differences in major, minor or intraoperative complications between ASD or CD patients, nor between expired vs living patients (all p>.05). Similarly, there were no significant differences in mortality overall within 30 days, between 30 and 90 days, nor >90 days after surgery between ASD or CD patient cohorts (all p>.05). Regression analysis revealed that when accounting for age, BMI and gender, only frailty status remained a significant predictor of death overall (p=.047). Mean survival time for ASD was 84.11 weeks versus 65.17 in CD patients(χ2(1)=.748, p=.387). Total 5-year all-cause mortality in adult spinal deformity and cervical deformity patients remains below 3% despite high rates of comorbidities, suggesting rigorous patient selection criteria plays an important role in maintaining the safety of such surgeries. This study demonstrates that while cervical deformity patients demonstrate greater incidence of death postoperatively, significantly increased baseline frailty status may be the principle cause of such results and should be considered when assessing surgical risks versus benefits. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) has enhanced the orthopedic surgical tool kit by introducing a broad range of analytical advances that may offer enhanced preoperative planning, intraoperative robotic or navigational guidance and prediction of postoperative complications. However, there remains a paucity of literature in regards to the utility of AI in adult spinal deformity (ASD)-corrective surgery. To access the impact of AI utilization on ASD-corrective surgery outcomes. Retrospective cohort. A total of 689 ASD patients. Artificial intelligence, perioperative complications, radiographic outcomes Operative ASD patients with complete baseline (BL) and 2-year (2Y) radiographic/HRQL data were stratified by AI-based utilization and robotic or navigational assistance in pre- and peri-operative course (AI+) or not (AI-). Corrections were based on AI models linked to age, proportional alignment and frailty status algorithms to predict outcomes, junctional failure and thoracic compensations. Means comparison tests and regression analysis assessed differences between patient groups. There were 158 patients included (57 AI+, 101 AI-). The cohort was 50% female, mean age of 58.8 yrs, BMI 31.6 kg/m2, CCI 3.9 and 6.6 levels fused. At baseline, patient groups were comparable in terms of BL radiographic parameters, all p <.05. Surgically, AI+ had significantly shorter operative times and EBL than AI-, both p <.05. AI+ had more combined approaches and less osteotomies overall, both p <.05. Postoperatively, AI+ patients were noted to have significantly improved segmental alignment in terms of decreased PT (p=0.006), and improved global alignment per decreased TPA and SVA by 2Y, both p < 0.05. Compared to AI-, AI+ patients had a lower overall complication rate by 2Y (28.1% vs 47.5%), p < 0.05. in a multivariate analysis controlling for age, CCI, and invasiveness, AI+ patients were 61.6% less likely to experience a perioperative complication (OR.384 [CI.149-.989], p=0.047). This study demonstrates that when using artificial intelligence-based technologies, patients demonstrated lower intraoperative invasiveness, increased likelihood of reaching radiographic alignment targets, and decreased complication rates specifically in the perioperative period. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Thoracic decompensation (TD) represents a distinct radiographic complexity from proximal junctional kyphosis (PJK). Few studies exist on the occurrence of TD following adult spinal deformity (ASD) corrective surgery. To assess the incidence of TD following ASD-corrective surgery in comparison with the occurrence of PJK. Retrospective cohort. A total of 689 ASD patients. ASD, TD, PJK, thoracic compensation. ASD patients with complete baseline (BL) and two-year (2Y) followup were included. Patients were divided into groups: those who developed TD: T4-T12 >54.2° and those who developed PJK. Further analysis assessed outcomes among patients with both TD and PJK (TDPJK). Thoracic compensation was defined as expected thoracic kyphosis minus BL thoracic kyphosis. Means comparison tests and multivariable logistic regression analysis assessed differences between patient groups. A total of 373 patients met inclusion criteria. Patient breakdown by radiographic outcome was: TD (N=31), PJK (N=223) and TDPJK (N=119). Age, gender, and ASD-mFI were similar between TD and PJK patients. TD patients were more likely to be osteoporotic than PJK patients, p < 0.05. Procedures on TD patients were less invasive and utilized a shorter construct (9.3 vs 11.5 levels; both p < 0.05). TD patients had significantly greater cervical lordosis, thoracic kyphosis, and lumbar lordosis than PJK patients at BL and 2Y follow-up, all p < 0.05. Thoracic compensation was significantly associated with TD (OR 1.07 [CI 1.04-1.09], p < 0.001) controlling for age, ASD-mFI, and invasiveness. TDPJK had the highest complication rate (84.9%), significantly greater than PJK patients (70.9%), and TD patients (61.3%), both p < 0.05. PJK patients were 78.7% less likely to develop PJF than TDPJK patients (OR 0.213 [CI 0.101-0.453], p < 0.001). Patients who developed thoracic decompensation were more likely to present with osteoporosis, but had less invasive procedures and levels fused than patients with proximal junctional kyphosis. The tradeoff between fusing too much resulting in proximal junctional kyphosis and fusing too little predisposing to thoracic decompensation can serve as the basis of future studies to determine optimal construct length to balance these two risks. Thoracic compensation was predictive of postoperative thoracic decompensation in adult spinal deformity-correction. Patients who developed TDPJK had the highest rate of complications and greater odds of junctional failure. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Recent literature has pointed to the rising use of prone lateral versus lateral decubitus positioning in minimally invasive spine surgery (MISS) as a method to reduce operative time, increase patient safety, and aid in surgical accessibility. However, there is a paucity of literature as to how prone lateral and lateral decubitus positioning compares in terms of reaching optimal postoperative outcomes and reducing complication rates. To assess differences between prone lateral and single-position lateral decubitus positioning compares in terms of reaching optimal postoperative outcomes and reducing complication rates. Retrospective review of prospective MIS database. A total of 524 MIS patients. HRQLs; complications; surgical factors. MISS patients with BL) and 2-year(2Y) postop radiographic/HRQL data were included. Patients positioned in the prone latera (PL) or single-position lateral decubitus (LD) position were isolated. At 2Y, an optimal outcome score was calculated using 4 equally weighted criteria: 1) achieving ideal PT per SRS-Schwab at 2Y, 2) Achieving ideal PI-LL per SRS-Schwab at 2Y, 3) No complication requiring reoperation, 4) Achieving NRS MCID by Salaffi et al. criteria; optimal score threshold was set at meeting 2 of 4 criteria. Means comparison analysis assessed differences in radiographic and clinical outcomes at BL and 1Y postoperatively. ANCOVA assessed estimated marginal means adjusting for BL age and revision status. Thirty-four PL and 36 LD patients were included (54.40±12.49 years, 40% female, 30.93±6.52 kg/m2, mean CCI: 2.23±1.55) were included. At baseline, patients were comparable in age, gender, BMI and CCI (all p>.05). Perioperatively, PL patients demonstrated significantly lower operative time (200.09 vs 284.54 min, p=.007) and EBL (332.35 vs 192.05 mL, p=.027). Though optimization scores were equivalent between groups (p=.160), PL patients demonstrated significantly lower perioperative complication rates (p=.012), neurological complication rates (p=.006), and had a fewer number of total complications by 2Y (p=.014). When controlling for BL age and revision status, the PL patients demonstrated consistently fewer intra- and perioperative complications as well (both p<.015). In terms of patient-reported outcomes, PL patients also demonstrated significantly improved NRS-Leg scores compared to LD patients by 1Y (p=.038). Patients placed in the PL position during minimally-invasive adult spinal deformity surgery demonstrate decreased mean operative times and decreased intraoperative invasiveness and blood loss versus patients operated on via single-position LD positioning. Though overall rates of achieving optimal outcome remain comparable, PL approach should be considered as there may be significant additional benefit in reducing peri- and postoperative complications by 2Y. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Advancements in artificial intelligence (AI), machine learning, and minimally-invasive (MIS) technique may offer enhanced preoperative planning, intraoperative robotic or navigational guidance, and prediction of postoperative complications for adult spinal deformity patients. Despite relatively widespread utilization, few studies in the literature assess the clinical and radiographic impact of AI in MIS surgery. To assess the impact of artificial intelligence on peri- and postoperative course in minimally-invasive adult spinal deformity corrective surgery. Retrospective cohort review. This study included 524 MIS patients. Intra- and postoperative complication rates; reoperation rate; HRQLs Operative cervical deformity patients 18 years old with complete pre-(BL) and up to 2-year (2Y) postop radiographic/HRQL data were stratified by primary utilization AI-based patient-specific rod customization and robotic or navigational assistance in pre- and perioperative course (AI+) or not (AI-). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors and complication rates were assessed via means comparison analysis. Analysis of covariance (ANCOVA) assessed postoperative complications while controlling for BL age and gender. A total of 133 MIS patients were included (51.74±11.59 years, 41% female, 30.85±6.93 kg/m2). Of these patients, 44 (33.1%) were classified as AI+. At baseline, patient groups were comparable in BL age, BMI and CCI (all p>.05), though AI+ patients were more likely to be male (p=.040). Patient groups were comparable in terms of both regional and global radiographic alignment, as well as HRQLs at BL (all p>.05). Surgically, AI+ patients had significantly shorter operative times overall (p=.022) and decreased EBL (p=.001), as well as decreased likelihood of undergoing corpectomy (p=.001). Furthermore, AI+ patients reported significantly lower hospital LOS vs AI- patients (p=.012). At 2 years postoperatively, AI+ patients with custom rods were noted to have significantly improved segmental alignment in terms of decreased pelvic tilt (S1PT) and pelvic incidence (S1PI) (both p <.001). Adjusted complications analysis revealed that AI+ patients were significantly less likely to experience any postoperative complication (p=.003), neurological complications (p=.021) or complication requiring reoperation (p=.003). Artificial intelligence and machine learning technologies may provide a substantial benefit to patients undergoing minimally-invasive adult spinal deformity surgery. The findings in this study demonstrate that patients operated on using AI-based robotic or navigational guidance, as well as the utilization of customized instrumentation, may reduce intraoperative invasiveness, shorten hospital length of stay, and decrease complication rates. As such, surgeons should consider utilization of AI-based technology in practice. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Previous studies have demonstrated that preoperative rehabilitation (prehab) may be beneficial in adult cervical deformity surgery. Though protocols vary widely, general overlap exists in terms of inclusion of mental and physical modalities in order to optimize patient outcomes. However, there remains a paucity of literature in regards to assessing outcomes in a controlled setting. To assess the effects of prehabilitation on peri- and postoperative outcomes in adult cervical deformity surgery. Retrospective review of prospective CD database. A total of 290 CD patients. Peri- and postoperative complication rates; medication usage; HRQLs. Operative CD patients 18yrs with complete pre-(BL) and 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in prehabilitation protocols beginning in 2019, consisting of physical therapy, nutritional counseling and/or psychological counseling. Patients were stratified as having underwent prehabilitation (Prehab+), versus those who did not (Prehab-). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors and complication rates were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales. QALY was calculated via NDI mapped to SF6D using validated methods. A total of 115 patients were included (56.37±8.90 years, 38% female, 29.84±6.19 kg/m2). Of these patients, 57 (49.6%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI and frailty. In terms of BL HRQLs, Prehab+ significantly lower mJOA scores (p=.047), though were equivalent in NDI and EQ5D scores (both p>.05). Baseline opioid usage was comparable prior to prehab enrollment (p=.093). Surgically, Prehab+ were able to undergo longer procedures (p=.017) with equivalent EBL (p=.627), and shorter SICU stay (p.05) and QALYs gained by 2Y (.43 vs.40, p>.05). This study demonstrates that introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling them to undergo longer surgeries with lessened risk of peri- and postoperative complications. Though cost-effectiveness of such programs should be further assessed, prehabilitation should be considered for eligible patients to assist in optimizing recovery and reducing complications or reoperations. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or weakened physiologic state. However, such studies have often been limited to two years, and longer-term studies are needed to better assess temporal changes in CD patients and associated mortality risk. To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery. Retrospective review of prospective cervical deformity (CD) database A total of 290 CD patients. Demographic factors; baseline comorbidities; intra/postoperative complications; mortality. Operative CD patients 18yrs with pre-(BL) and 10-year (10Y) data were included. Patients were stratified as Expired vs Living, as well as temporally grouped by Expiration prior to 5Y or between 5Y and 10Y. Group differences were assessed via means comparison analysis. Backstep logistic regression identified mortality predictors. Kaplan-Meier analysis assessed survivorship of expired patients. Log rank analysis determined differences in survival distribution groups. Sixty-six total patients were included (58.11 ± 11.97 years, 48% female, 29.13 ± 6.89 kg/m2). Within 10Y, 20 (27.3% of CD cohort). At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p.001). KM analysis found that by Passias et al., frailty, not frail patients had mean survival time of 170.56 weeks, vs 158.00 in frail patients (p=.949). This study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status and minimizing fusion length when appropriate, surgeons may be able to further assist CD patients in increasing their survivability post-operatively. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The single position minimally invasive (MIS) approach allows access to the anterior and posterior columns with the ability to mitigate complications associated with open procedures while achieving circumferential fusion. The purpose of this study was to identify if patient weight or body mass index (BMI) leads to differences in intraoperative event rates. To determine if patient weight and BMI will correlate with the occurrence of intraoperative events during MIS spine surgery. Retrospective cohort. A total of 524 MIS patients. Weight (kg), BMI (kg/m2), Aborted procedures, estimated blood loss (EBL), operative time (OpTime). Of 524 patients eligible, 226 (43.1%) had available data. Of these, 88 met inclusion criteria (52 Lat and 36 PL). The majority were male (49, 55.7%), mean age of 49.2 yrs and 2.0 levels fused and 18 (20.5%) undergoing an osteotomy. Lat patients with a weight > 130 kg had significantly longer OpTime (p=0.003) and more EBL (p=0.019). There was a significant difference in mean weight for lat patients with (121.8 kg) and without (97.7 kg) an aborted procedure, p=0.021. There was also a significant difference in mean BMI for lat patients with (35.3 kg/m2) and without (29.6 kg/m2) an aborted procedure, p=0.015. Multivariable analysis showed that weight (OR 1.03 [CI 1.01-1.06], p=.020) and BMI (OR 1.15 [CI 1.02-1.30], p=.026) were independent predictors for aborted procedures in lat patients. In an analysis of PL patients, there was one aborted case (weight > 120 kg), but no significant findings for EBL or OpTime. Of 524 patients eligible, 226 (43.1%) had available data. Of these, 88 met inclusion criteria (52 Lat and 36 PL). The majority were male (49, 55.7%), mean age of 49.2 yrs and 2.0 levels fused and 18 (20.5%) undergoing an osteotomy. Lat patients with a weight > 130 kg had significantly longer OpTime (p=0.003) and more EBL (p=0.019). There was a significant difference in mean weight for lat patients with (121.8 kg) and without (97.7 kg) an aborted procedure, p=0.021. There was also a significant difference in mean BMI for lat patients with (35.3 kg/m2) and without (29.6 kg/m2) an aborted procedure, p=0.015. Multivariable analysis showed that weight (OR 1.03 [CI 1.01-1.06], p=.020) and BMI (OR 1.15 [CI 1.02-1.30], p=.026) were independent predictors for aborted procedures in lat patients. In an analysis of PL patients, there was one aborted case (weight > 120 kg), but no significant findings for EBL or OpTime. Weight and BMI appear to be independently associated with aborted procedures for patients in the lateral decubitus position during minimally invasive spine surgery. Patients in the lateral decubitus position who weighed 130 kg or more had on average longer operative times and more estimated blood lost. This study has the potential to help with risk stratification in the future when determining patients undergoing a single position procedure. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Pelvic incidence (PI) serves as the cornerstone for many deformity classifications and realignment schema to create a more individualized realignment target for each patient. Yet, previous literature has linked high PI to problematic outcomes following corrective surgery, including mechanical complications and hip pathologies. Investigate if patients with high pelvic incidence have increased risk for complications and poor clinical outcomes following ASD surgery. Retrospective. A total of 689 ASD patients. Clinical Outcomes (ODI, SF-36 PCS, MCS), mechanical failure, surgical details. ASD patients with 2-year (2Y) data included. Groups: PI >65° (HighPI) versus PI < 65° (NormPI). Means comparison tests assessed differences in demographics, surgical details and outcomes between groups. Multivariate analysis controlling for baseline age, frailty, baseline PI-LL, and history of prior fusion, analyzed complication rates and clinical improvement between groups. Included: 445 ASD patients. There were 94 (21%) patients presented with a BL pelvic incidence greater than 65° (HighPI). HighPI patients were older (63 yrs), shorter, with higher BMI and frailty (all p<.05). HighPI were more likely to have had a prior fusion (OR: 1.9, [1.2-3.1]). HighPI were more likely to present with lower physical functioning scores, and severe pelvic compensation (OR: 5.5, [3.4-8.9]) and global deformity (OR: 3.5, [2.2-5.6]). During surgery, HighPI underwent more 3COs (OR: 1.8,[1.1-3.1]) and fusion to pelvis (OR: 2.1,[1.1-3.9]). Upon correction, adjusted analysis revealed HighPI were more likely to be undercorrected in each age-adjusted parameter compared to LowPI (OR: 4.8, [2.9-7.8]). Yet, HighPI patients were less likely to deteriorate within in-construct PI-based alignment (relative lordosis and lordosis distribution) (OR: 0.3,[0.1-0.9]). While not different at six weeks, HighPI were more likely to deteriorate in PI-based global alignment and pelvic compensation from six weeks to two years (OR: 3.2, [1.6-6.5]). This translated to a higher likelihood of developing a major or mechanical complication by 2Y (OR: 1.6, [1.04-2.6]) via adjusted analysis. High pelvic incidence is associated with increased frailty, decreased physical functioning, and more severe lumbopelvic and global deformity upon presentation for adult spinal deformity correction. These patients are more often undercorrected by age-adjusted standards and deteriorate in out-of-construct alignment over time even when adequately corrected, leading to higher mechanical complications by two years. Despite our focus on PI-adjusted alignment, we have still not optimized treatment for the patient with high pelvic incidence. Further research should target which surgical techniques and strategies can achieve better results in this population. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

A previous study by Pellisé et al identified strong preoperative and surgical predictors of major complications. It is unknown which of these risk factors has the most significant impact on cost-effectiveness. To assess the impact of previously established risk factors on the cost effectiveness of ASD surgery. Retrospective. A total of 689 ASD patients. Quality adjusted life years (QALYs), utility gained, ODI, total cost. ASD patients with baseline (BL) and 2-year postoperative (2Y) data were included. Frailty score, sagittal deformity measures (SVA, PI-LL, T1 Sagittal Tilt), blood loss and surgical time were divided into tertiles, with the highest tertile being classified as high risk. Since some patients have multiple risk factors, they may be included in multiple groups. Descriptive analysis identified demographics, radiographic parameters and surgical factors. Published methods for cost was calculated using the PearlDiver database and CMS.gov definitions. Cost per QALY at 2Y was calculated for each risk factor. There were 422 patients included. Of the 381 patients with a risk factor, 77% were fused to the pelvis, 44% were highly frail, 56% had a high deformity, 34% had high EBL and 34% had high operative time. When analyzing BL scores, highly frail patients had the highest mean ODI and EQ-5D. After undergoing surgery, patients with a high EBL had the highest rate of SICU admissions, rate of any complications and rate of major complications. This translated to patients with high EBL having the lowest utility gained at 2Y. Interestingly, patients with high frailty had the highest rates of implant complications and pseudarthrosis resulting in the second highest major complication rates and total estimated cost. Despite this high estimated cost, however, patients with high frailty also achieved the highest utility gained at 2Y resulting in the best cost-utility at two years. Despite having higher rates of implant failures, pseudarthrosis, and major complications, highly frail patients managed to generate the highest utility gained and best cost-effectiveness, while higher blood loss had higher rates of complications as well, but demonstrated the lowest utility gained and cost-utility. Therefore, spine surgeons should limit intraoperative risk factors, such as blood loss and operative time, which would minimize postoperative complications and improve overall cost-effectiveness during correction of adult spinal deformity. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The single position minimally invasive (MIS) lateral approach allows access to the anterior and posterior columns with the patient positioned in the lateral decubitus position. The purpose of this approach was to mitigate complications associated with open procedures while achieving circumferential fusion. More recently, an alternative prone-lateral technique has been developed streamlining surgical access with potential advantages. The purpose of this study was to identify differences in intraoperative neurophysiological monitoring (IOM) event rates between single position lateral decubitus and prone-lateral patients during MIS spine surgery. To determine if lateral decubitus positioning will correlate with the occurrence of neurophysiological monitoring events during MIS spine surgery. Retrospective cohort. A total of 524 MIS patients were included. Intraoperative neurophysiological monitoring, lateral decubitus, prone lateral. MIS spine surgery patients with available surgical positioning and IOM data were included if they were in a single position. Patients were stratified into 2 groups based on operative positioning: lateral decubitus (Lat) and prone lateral (PL). IOM was performed using somatosensory evoked potentials (SSEPs) and electromyography (EMG) techniques. An abnormal event was defined as any confirmed loss of signal during the operative period in the anatomical distribution of the surgery. Means comparison tests and multivariable logistic regression analysis assessed differences between patient groups. Of 524 patients eligible, 226 (43.1%) had available positioning and IOM data. Of these, 88 met inclusion criteria (52 Lat and 36 PL). The majority were male (49, 55.7%), mean age of 49.2 yrs and 2.0 levels fused and 18 (20.5%) undergoing an osteotomy. In total, 19 (21.6%) patients had an abnormal IOM event. There was a significant difference in abnormal IOM event rates for patients who were in Lat (31%) and PL (8%) positioning, p=0.012. Multivariable analysis adjusting for surgical invasiveness showed that PL patients were 76.8% less likely to experience an abnormal IOM event than Lat patients (OR.232 [CI.060-.905], p=.035). Of the Lat patients with an abnormal IOM, 6.3% had postoperative sensory loss in the saphenous nerve. Lateral decubitus positioning appears to be independently associated with abnormal intraoperative neurophysiological monitoring events when compared to prone lateral positioning during MIS. This has the potential to help with risk stratification in the future when determining patients undergoing a single position procedure. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Despite multiple reports showing favorable long-term functional outcomes following adult spinal deformity (ASD) correction, it is still unclear which patient factors may impact the sustainability of these outcomes. To assess the sustainability of functional gains following ASD correction and determine predictors for postoperative loss of patient functionality. Retrospective cohort. A total of 689 ASD patients. Sustained clinical benefit, Oswestry Disability Index (ODI), reoperation, mechanical failure, proximal junctional failure (PJF) ASD patients with baseline (BL) and three-year (3Y) follow-up data were considered for analysis. Only patients who met the definition of sustained clinical benefit (SCB) at one-year (1Y) were included: 1)Passias et al's threshold for ODI (ODI<31.3), 2) did not develop PJF, and 3) did not have a reoperation for a mechanical failure. Patient groups were created by those who met SCB at 3Y, and those who did not. SCB outcomes were also reported at five-years (5Y) postoperatively. Means comparison tests assessed differences in patient groups. Factors predicting SCB were identified using adjusted regression and conditional inference tree (CIT) analysis. A total of 157 patients met inclusion criteria and had SCB at 1Y. Patient breakdown for SCB was 75.0% at 3Y. Gender (78% vs 81%), BMI (25.5 vs 26.4), levels fused (10.6 vs 10.5), operative time (345 vs 362 min), and surgical invasiveness were similar between groups, all P>.05. Following surgery, patient groups were similarly aligned to Lafage et al's age-adjusted PT, PI-LL, and SVA, all P>.05. Regression and CIT analysis adjusting for BL deformity determined that patients who met SCB at 3Y were 95.4% less likely to have an ASD-mFI score > 11 (.046[.005-.420], p=0.006), 73.1% less likely to be older than 55 years at DOS (.269[.091-.798], p=.018), 69.4% less likely to have a CCI score > 0(.306[.116-.811], p=.017), and 86.9% less likely to have a BL EQ5D score <.723 (.131[.029-.585], p=.008). Adjusted for patients without follow-up, sustained clinical benefit at 5Y was 57.9%. Predictors of SCB from 3Y to 5Y included age, CCI and EQ5D, all P <.05. Sustained clinical benefit was maintainable for 75.0% of the operative ASD cohort at 3Y. Similarly, a 57.9% maintenance rate of sustained clinical benefit at 5Y reflects the longevity of ASD correction. Independent predictors of sustained clinical benefit included age, frailty, comorbidities and the patient health state. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Preoperative rehabilitation programs have recently been implemented to prepare patients for surgery and to promote patient health. In this cohort, preoperative rehabilitation consisted of physical and mental components. Patients were referred for physical therapy for 3 months, 3 days a week for core, paraspinal and leg strengthening, with a review of postop protocols to do at home, including gait and balance training. Patients were also referred for cognitive behavioral therapy for 2 weeks to prepare for the stress of surgery. Patients were excluded if they presented with any of the following at baseline (BL): severe neurological deficit (<3/5), minimal ambulation or current depression/anxiety. Identify if preoperative rehabilitation influences patients' ability to recover and adult spinal deformity correction cost-effectiveness. Retrospective cohort. This study included 689 adult spinal deformity patients. Preoperative rehabilitation, recovery kinetics, cost effectiveness. Adult spinal deformity patients with baseline (BL) and two-year (2Y) follow-up, and available preoperative rehabilitation and economic data were included. Patients were divided on whether or not they completed a preoperative rehabilitation assignment (Prehab) or not (no Prehab). Normalized HRQL scores at BL and follow-up intervals (6W, 1Y, 2Y) were generated. Normalized HRQLs were plotted and area under the curve was calculated, generating one number describing overall recovery (Integrated Health State [IHS]). Cost was calculated using the PearlDiver database. This data is representative of national average Medicare cost differentiated by complication/comorbidity outcome, surgical approach, and revision status. Cost per quality-adjusted life year (QALY) at 2Y were calculated. Multivariate logistic regression analysis assessed patient reported outcomes and cost adjusting for baseline and surgical characteristics. A total of 100 patients were included (36 Prehab, 64 no Prehab). Age (59.2 vs 56.2), gender (F: 58% vs 45%), body mass index (32.9 vs 31.4), and Charlson Comorbidity Index (3.8 vs 3.9) were similar between groups (P >0.05). OpTime, EBL, and length of construct were similar between groups (p >0.05). Normalized HRQLs determined Prehab patients to exhibit better ODI than no Prehab patients at 2Y follow-up, p 0.05. Cost effectiveness was determined via cost per QALY: Prehab = $14,463 and not Prehab = $45,515, p <0.05. Patients who had a preoperative rehabilitation prior to corrective surgery were in a better state of postoperative back disability at two-year follow-up. While both patient cohorts had improvement following surgery, patients with preoperative rehabilitation had greater utility gained at two-year follow-up. Costs by procedure and cost effectiveness were better for patients who had preoperative rehabilitation. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical correction of cervical deformity is a proven treatment option that provides functional restoration and pain relief. It is unclear whether patient outcomes and costs of the procedure are influenced by the time between initial symptom onset and definitive surgical intervention. This study sought to determine how long nonoperative treatment should be exhausted prior to offering surgery for cervical deformity. To identify whether delayed procedures influence patients' ability to recover and cervical deforminty corrective surgery cost effectiveness. Retrospective cohort. This study included 290 cervical deformity patients. Delayed surgical intervention, recovery kinetics, cost effectiveness. Cervical deformity patients with baseline (BL) and two-year (2Y) follow-up data were included. Patients were stratified by time to surgery following the onset of their neck pain: >5 years=Delayed; <5 years=not Delayed. Normalized HRQL scores at BL and follow-up intervals (3M, 6M, 1Y, 2Y) were generated. Normalized HRQLs were plotted and area under the curve was calculated, generating one number describing overall recovery (Integrated Health State [IHS]). Cost was calculated using the PearlDiver database, which represents national average Medicare cost. Cost per Quality-Adjusted Life Year (QALY) at 2Y was calculated. Multivariable regression analysis assessed the impact of Delayed surgery on patient outcomes and cost. A total of 123 patients were included (54 Delayed, 69 not Delayed). Demographic and surgical characteristics were similar between groups (p > 0.05). Normalized HRQLs showed that Delayed patients exhibit worse NDI and NRS Neck at 2Y follow-up, both p 0.05. Utility gained at 2Y follow-up was 0.172 for Delayed and 0.2847 for not Delayed. This translated to QALY gained at 2Y of 0.334 for Delayed and 0.553 for not Delayed, p 0.05. Multivariable analysis found Delayed patients were less likely to gain utility (OR 0.125 [CI 0.019-0.840]) and QALYs (OR 0.343 [CI 0.129-0.914]) at 2Y postoperatively, both p< 0.05. Patients who had a 5-year or greater delay to surgery from the onset of neck pain had more significant postoperative neck disability. Cost by procedure and cost-effectiveness when stratified by time to surgery following enrollment were comparable. While both patient cohorts had postop improvement, patients without delay had greater utility gained and quality adjusted life years at 2-year follow-up. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Minimally invasive (MIS) spine surgery techniques were developed to mitigate complications associated with open procedures while achieving functional outcomes. More recently, preoperative rehabilitation programs have been implemented to prepare patients for surgery and to promote patient health. The purpose of this study was to identify the effect of preoperative rehabilitation on MIS spine surgery patient outcomes. Identify if preoperative rehabilitation influences patient outcomes following MIS spine surgery. Retrospective cohort. This study included 524 MIS patients. Preoperative rehabilitation, perioperative complications, patient outcomes. MIS spine surgery patients with baseline (BL) and two-year (2Y) follow-up were included if they had preoperative rehabilitation data. Patients were divided into two groups: those who had preoperative rehabilitation [Prehab] and those who did not [no Prehab]. Prehab consisted of physical and mental components, ie, physical therapy for 3 months, 3 days a week for core, paraspinal and leg strengthening, with a review of postop protocols to do at home, including gait and balance training. Patients were also referred for cognitive behavioral therapy for 2 weeks to prepare for the stress of surgery. Patients were excluded if they presented with any of the following at baseline: severe neurological deficit (< 3/5), minimal ambulation, or current depression/anxiety. Means comparison tests and logistic regression analysis controlling for age, CCI, ASA grade, and invasiveness assessed differences between patient groups. Conditional inference tree (CIT) analysis determined thresholds for continuous variables. A total of 216 patients met inclusion criteria (76 Prehab, 140 no Prehab). The majority were male (97, 44.9%), mean age of 55.17 years, and 2.3 levels fused and 28 (13.0%) undergoing 3-CO. There was a significant difference in LOS for patients who had (3.6 days) and didn't have (5.3 days) Prehab, p <.05. Multivariate regression showed that Prehab was an independent predictor of a shorter LOS (OR.686 [CI.484-.972], p=.034). CIT analysis determined Prehab patients were 85.0% less likely to have a LOS greater than 2.0 days (OR.015 [CI.001-.258], p=.004). By 2 years, Prehab patients had lower rates of readmissions (6.7% vs 20.0%) and reoperations (4.0% vs 15.3%) than no Prehab patients, both p <.05. Preoperative rehabilitation appears to be independently associated with a shorter length of stay following minimally invasive spine surgery. Patients who had preoperative rehabilitation also had lower rates of readmissions and reoperations by two years postoperatively. This abstract does not discuss or include any applicable devices or drugs. [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]

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]

Distal junctional kyphosis (DJK) development after cervical deformity (CD) corrective surgery is a growing concern for surgeons and patients. Although proper realignment is known to help mitigate the development of DJK, there has yet to be a study that critically analyzes under correction in certain parameters and the effects on development of DJK. To determine the effects of under correction in the development of DJK. Retrospective cohort study of single-center database. This study included 195 CD patients. Complications; radiographic parameters; HRQL metrics (NDI, EQ5D, mJOA, NRS Neck). Inclusion criteria: operative CD patients (cervical kyphosis >10°, with cSVA>4cm or CBVA>25°) and >18yrs with up to 2-year radiographic and HRQL follow-up. Significant differences in surgical, radiographic, and clinical factors and outcomes were determined. Under correction was defined by a deformity in TS-CL or cSVA Ames Modifier. Moderate Ames cervical lordosis deformity (CL) was TS-CL >15 and high >20, high cSVA deformity was >8cm. A total of 195 CD patients met inclusion criteria (58.3yrs, 46% Female, 28.3 kg/m2). Overall, 40 (21%) of these patients developed DJK. At baseline patients presented with the following radiographic profile: PT (18.3), PI-LL (-.65), SVA C7-S1 (-6.54), cSVA C2-C7 (9.7), and TS-CL (24). Patients undercorrected in TS-CL developed DJK at a greater rate (28% vs 15%, p=.02), and patients undercorrected in cSVA developed more DJK (65% vs 16%) and underwent more reoperations (42% vs 17%, both p<0.05). Controlling for baseline deformity, frailty and age, patients who maintained a high cSVA deformity had a 3.2 times higher likelihood of developing DJK (3.2[1.6-6.8], p=.002). Patients with a postoperative moderate CL deformity had a 1.8 times higher likelihood of DJK (1.8[.9-3.8], p=.105), and with a high CL deformity, a 2.8 times higher likelihood (2.8[1.1-7.2], p=.03). Controlling for the same factors, patients who remained undercorrected in both cSVA and TS-CL had a 6 times times higher likelihood of developing DJK (6[1.9-17], p=.002). Using CIT to find a threshold cutoff, the risk of DJF was considerably increased for patients with a TS-CL greater than 13.5, (2.4[1.14-5], p=.026), and a cSVA deformity greater than 6cm (3.2[1.5-6.6], p=.026). Patients who were adequately corrected in cSVA and undercorrected in TS-CL demonstrated no significant increased vulnerability to DJK, (p>0.05). The TS-CL and cSVA components of Ames criteria show a strong correlation with development of distal junctional kyphosis (DJK). Thresholds for DJK development suggests even patients who fall into a mild deformity as per the Ames criteria are still at an increased risk, and more strict alignment goals may further prevent mechanical failure. cSVA was found to be the dominant radiographic parameter impacting DJK development. 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]

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]

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]

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]