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Background: Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), although patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD corrective surgery with regard to HK and hyperlordosis (HL). Objective: The objective of the study is to evaluate patterns in treatment for CD patients with baseline (BL) HK and HL and understand how extreme curvature of the spine may influence surgical outcomes. Materials and Methods: Operative CD patients with BL and 1-year (1Y) radiographic data were included in the study. Patients were stratified based on BL C2–C7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (−6.96 ± 21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (<−28.43°) depending on directionality. Patients within 1SD were considered control group. Results: 102 surgical CD patients (61 years, 65% F, 30 kg/m2) with BL and 1Y radiographic data were included. 20 patients met definitions for HK and 21 patients met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with posterior approach. Operative time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-SVA (10.8 vs. 7.0 vs. −47.8 mm, P = 0.001). HL patients had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had 3x revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL patients had higher cSVA and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK patients had higher McGregor's slope (MGS) (16.1° vs. 3.3°, P = 0.002) and C0–C2 Cobb (43.3° vs. 26.9°, P < 0.001), however, postoperative differences in MGS and C0–C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary CT (38.1%), UT (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1-year postoperative, perhaps due to undercorrection compared to kyphotic etiologies. [ABSTRACT FROM AUTHOR]

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

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

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

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 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]

Study Design. Retrospective cohort study. Objective. This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery. Summary of Background Data. The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions. Methods. Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes. Results. After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P<0.001). Each index established significant (all P<0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P<0.001), whereas MF increased (9.2% to 16.2%, P<0.001), and SF remained constant (2% to 1.6%, P>0.05). With increase in severity, postoperative rates of morbidities and complications increased. Conclusion. The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort.Objective: The aim was to describe the two-year outcomes for patients undergoing surgical correction of cervical deformity (CD).Background: Adult CD has been shown to compromise health-related quality of life. While advances in spinal realignment have shown promising short-term clinical results in this parameter, the long-term outcomes of CD corrective surgery remain unclear.Materials and Methods: Operative CD patients >18 years with two-year (2Y) health-related quality of life/radiographic data were included. Improvement in radiographic, neurologic, and health-related quality of life outcomes were reported. Patients with a prior cervical fusion and patients with the greatest and smallest change based on Neck Disability Index (NDI), numeric rating scale (NRS) neck, modified Japanese Orthopaedic Association (mJOA) were compared using multivariable analysis controlling for age, and frailty, and invasiveness.Results: One hundred and fifty-eight patients were included in this study. By 2Y, 96.3% of patients improved in Ames cervical sagittal vertical axis modifier, 34.2% in T1 slope minus cervical lordosis (TS-CL), 42.0% in horizontal gaze modifier, and 40.9% in SVA modifier. In addition, 65.5% of patients improved in Passias CL modifier, 53.3% in TS-CL modifier, 100% in C2-T3 modifier, 88.9% in C2S modifier, and 81.0% in MGS modifier severity by 2Y. The cohort significantly improved from baseline to 2Y in NDI, NRS Neck, and mJOA, all P <0.05. 59.3% of patients met minimal clinically important difference for NDI, 62.3% for NRS Neck, and 37.3% for mJOA. Ninety-seven patients presented with at least one neurologic deficit at baseline and 63.9% no longer reported that deficit at follow-up. There were 45 (34.6%) cases of distal junctional kyphosis (DJK) (∆DJKA>10° between lower instrumented vertebra and lower instrumented vertebra-2), of which 17 were distal junctional failure (distal junctional failure-DJK requiring reoperation). Patients with the greatest beneficial change were less likely to have had a complication in the two-year follow-up period.Conclusion: Correction of CD results in notable clinical and radiographic improvement with most patients achieving favorable outcomes after two years. However, complications including DJK or failure remain prevalent. [ABSTRACT FROM AUTHOR]

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

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]

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]

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]

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

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

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

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

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]