Search

OBJECTIVE Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. METHODS This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. RESULTS Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7–71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1–61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher’s exact test). CONCLUSIONS The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.

OBJECTIVE The objective of this study was to evaluate spinopelvic sagittal alignment and spinal compensatory changes in adult cervical kyphotic deformity. METHODS A database composed of 13 US spine centers was retrospectively reviewed for adult patients who underwent cervical reconstruction with radiographic evidence of cervical kyphotic deformity: C2–7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, or cervical kyphosis (T1 slope [T1S] cervical lordosis [CL] > 15°) (n = 129). Sagittal parameters were evaluated preoperatively and in the early postoperative window (6 weeks to 6 months postoperatively) and compared with asymptomatic control patients. Adult cervical deformity patients were further stratified by degree of cervical kyphosis (severe kyphosis, C2–T3 Cobb angle ≤ −30°; moderate kyphosis, ≤ 0°; and minimal kyphosis, > 0°) and severity of sagittal malalignment (severe malalignment, sagittal vertical axis T3–S1 ≤ −60 mm; moderate malalignment, ≤ 20 mm; and minimal malalignment > 20 mm). RESULTS Compared with asymptomatic control patients, cervical deformity was associated with increased C0–2 lordosis (32.9° vs 23.6°), T1S (33.5° vs 28.0°), thoracolumbar junction kyphosis (T10–L2 Cobb angle −7.0° vs −1.7°), and pelvic tilt (PT) (19.7° vs 15.9°) (p < 0.01). Cervicothoracic kyphosis was correlated with C0–2 lordosis (R = −0.57, p < 0.01) and lumbar lordosis (LL) (R = −0.20, p = 0.03). Cervical reconstruction resulted in decreased C0–2 lordosis, increased T1S, and increased thoracic and thoracolumbar junction kyphosis (p < 0.01). Patients with severe cervical kyphosis (n = 34) had greater C0–2 lordosis (p < 0.01) and postoperative reduction of C0–2 lordosis (p = 0.02) but no difference in PT. Severe cervical kyphosis was also associated with a greater increase in thoracic and thoracolumbar junction kyphosis postoperatively (p = 0.01). Patients with severe sagittal malalignment (n = 52) had decreased PT (p = 0.01) and increased LL (p < 0.01), as well as a greater postoperative reduction in LL (p < 0.01). CONCLUSIONS Adult cervical deformity is associated with upper cervical hyperlordotic compensation and thoracic hypokyphosis. In the setting of increased kyphotic deformity and sagittal malalignment, thoracolumbar junction kyphosis and lumbar hyperlordosis develop to restore normal center of gravity. There was no consistent compensatory pelvic retroversion or anteversion among the adult cervical deformity patients in this cohort.

Frailty is influential in determining operative outcomes, including complications, in patients with cervical deformity (CD).To assess whether frailty status limits the highest achievable outcomes of patients with CD.Adult patients with CD with 2-year (2Y) data included. Frailty stratification: not frail (NF)0.2, frail (F) 0.2 to 0.4, and severely frail (SF)0.4. Analysis of covariance established estimated marginal means based on age, invasiveness, and baseline deformity, for improvement, deterioration, or maintenance in Neck Disability Index (NDI), Modified Japanese Orthopaedic Association (mJOA), and Numerical Rating Scale Neck Pain.One hundred twenty-six patients with CD included 29 NF, 83 F, and 14 SF. The NF group had the highest rates of deterioration and lowest rates of improvement in cervical Sagittal Vertical Axis and horizontal gaze modifiers. Two-year improvements in NDI by frailty: NF: -11.2, F: -16.9, and SF: -14.6 ( P = .524). The top quartile of NF patients also had the lowest 1-year (1Y) NDI (7.0) compared with F (11.0) and SF (40.5). Between 1Y and 2Y, 7.9% of patients deteriorated in NDI, 71.1% maintained, and 21.1% improved. Between 1Y and 2Y, SF had the highest rate of improvement (42%), while NF had the highest rate of deterioration (18.5%).Although frail patients improved more often by 1Y, SF patients achieve most of their clinical improvement between 1 and 2Y. Frailty is associated with factors such as osteoporosis, poor alignment, neurological status, sarcopenia, and other medical comorbidities. Similarly, clinical outcomes can be affected by many factors (fusion status, number of pain generators within treated levels, integrity of soft tissues and bone, and deformity correction). Although accounting for such factors will ultimately determine whether frailty alone is an independent risk factor, these preliminary findings may suggest that frailty status affects the clinical outcomes and improvement after CD surgery.

Literature review.The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes.There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure.A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed.Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures.By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.

ObjectiveSurgery for spinal deformity has the potential to improve pain, disability, function, self-image, and mental health. These surgeries carry significant risk and require careful selection, optimization, and risk assessment. Epigenetic clocks are age-estimation tools derived by measuring methylation patterns of specific DNA regions. The study of biological age in the adult deformity population has the potential to shed insight on the molecular basis of frailty and improve current risk assessment tools.MethodsAdult patients undergoing deformity surgery were prospectively enrolled. Preoperative whole blood was used to assess epigenetic age and telomere length. DNA methylation patterns were quantified and processed to extract 4 principal component (PC)-based epigenetic age clocks (PC Horvath, PC Hannum, PC PhenoAge, and PC GrimAge) and the instantaneous pace of aging (DunedinPACE). Telomere length was assessed using both qPCR (T/S ratio) and methylation-based telomere estimator (PC DNAmTL). Patient demographic and surgical data included age, BMI, American Society of Anesthesiology (ASA) classification, and Charlson Comorbidity Index (CCI), Adult Spinal Deformity Frailty Index (ASD-FI), Edmonton Frail Score (EFS), Oswestry Disability Index (ODI), and Scoliosis Research Society-22r (SRS-22). Medical or surgical complications within 90 days of surgery were collected. Spearman correlations and log-odd ratios derived from linear regression analyses, adjusted for gender and BMI, were performed.ResultsEighty-six patients were enrolled with mean age of 65 years and 46 women (54%). All patients underwent a posterior fusion with a mean of 11 levels fused and 35 3-column osteotomies (41%). Among epigenetic clocks, DunedinPACE showed a significant association with ASD-FI, EFS, ASD-FI, and SRS-22 – higher pace of aging was associated with worse frailty and disability scores. PC PhenoAge showed significant associations with EFS, ASD-FI, and ODI. PC GrimAge showed significant associations with EFS and ASD-FI. Among telomere measurements, PC DNAmTL was associated with CCI. There was a significant association between increased pace of aging by DunedinPACE and postoperative complications.ConclusionsDunedinPACE showed significant associations with markers of frailty (EFS, ASD-FI), disability (ODI, SRS-22), and postoperative complications. These data suggest a role for aging biomarkers as components of surgical risk assessment. Integrating biological age into current risk calculators may improve their accuracy and provide valuable information for patients, surgeons, and payers.

Justin K Scheer,1 Fabíola Costa,2 Dora Janela,2 Maria Molinos,2 Anabela C Areias,2 Robert G Moulder,3 Jorge Lains,4,5 Virgílio Bento,2 Vijay Yanamadala,2,6,7 Fernando Dias Correia2,8 1Department of Neurological Surgery, University of California, San Francisco, CA, USA; 2Sword Health, Inc, Draper, UT, USA; 3Institute for Cognitive Science, University of Colorado Boulder, Boulder, CO, USA; 4Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal; 5Faculty of Medicine, Coimbra University, Coimbra, Portugal; 6Department of Surgery, Quinnipiac University Frank H. Netter School of Medicine, Hamden, CT, USA; 7Department of Neurosurgery, Hartford Healthcare Medical Group, Westport, CT, USA; 8Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, PortugalCorrespondence: Fernando Dias Correia, Sword Health Inc, 13937 Sprague Lane Ste 100, Draper, UT, 84020, USA, Tel +1 385-308-8034, Fax +1 801-206-3433, Email fcorreia@swordhealth.comBackground: Musculoskeletal (MSK) pain is highly prevalent worldwide, resulting in significant disability, and comorbid sleep disturbances. Digital therapy for MSK pain can provide significant improvements in care access, alongside pain and disability reductions. However, studies on the effect of such programs on sleep are lacking.Purpose: To evaluate the impact on pain-related sleep impairment after a 12-week remote multimodal digital care program (DCP) for MSK conditions.Patients and Methods: This is an ad-hoc analysis of a decentralized single-arm study into engagement and clinical outcomes after a DCP for MSK rehabilitation. Patients were stratified by baseline sleep disturbance, based on sleep questions in the questionnaires: Oswestry Disability Index, Neck Disability Index, and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire. Additional outcomes were pain, Generalized Anxiety Disorder 7-item scale, Patient Health 9-item questionnaire, Work Productivity, and Activity Impairment, and program engagement.&#x00A0Results: At baseline, 5749 patients reported sleep disturbance (78.0% of eligible patients). These reported significantly worse clinical outcomes at baseline than patients without sleep disturbance (all p< 0.001). Patients with comorbid sleep disturbance showed improvements in sleep, with a significant proportion reporting full recovery at program completion: 56% of patients with upper limb conditions (including 10% of patients with severe sleep disturbance at baseline), and 24% with spine conditions. These patients also reported significant improvements in all clinical outcomes at program completion. Engagement and satisfaction were high, and also higher than in patients without sleep impairment.Conclusion: This is the first study of its kind investigating the effect of a completely remote DCP for MSK pain on sleep. Patients reporting comorbid sleep disturbance had significant improvement in sleep, alongside pain, mental health and work productivity at program completion. The results suggest that a DCP for MSK pain can improve sleep disturbances in patients with upper limb and spine conditions.Keywords: pain, physical therapy, eHealth, telerehabilitation, remote care

OBJECTIVE Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-recognized complications of long-segment spinal fusion. Previous studies have suggested that ligament augmentation can decrease rates of PJF by reducing junctional stress and strengthening upper instrumented vertebrae (UIVs) and adjacent segments. However, there is a paucity of long-term data on the efficacy of ligament augmentation in preventing PJF. In this study, the authors sought to determine the effect of ligament augmentation on rates of PJF in a cohort of adult spinal deformity patients with at least 1 year of follow-up. METHODS They conducted a retrospective analysis of ligament augmentation in a consecutive series of surgical patients with adult spinal deformity. Data on patient demographics, surgical characteristics, and surgery for PJF were collected. The minimum follow-up was 12 months. Univariate and multivariate analyses were performed to identify factors associated with reoperation for PJF. RESULTS The authors identified a total of 242 patients (166 women [68.6%]) with ligament augmentation whose mean age was 66 years. The mean number of fused levels was 10, with a UIV distribution as follows: 90 upper thoracic UIVs (37.2%) and 152 lower thoracic UIVs (62.8%). Compared to a historical cohort of 77 patients treated before implementation of ligament augmentation, reoperation for PJF was significantly lower with ligament augmentation (15.6% vs 3.3%, p < 0.001). In a multivariate model, only ligament augmentation (OR 0.184, 95% CI 0.071–0.478, p = 0.001) and number of fused levels (OR 0.762, 95% CI 0.620–0.937, p = 0.010) were associated with reductions in reoperation for PJF. CONCLUSIONS Ligament augmentation was associated with significant reductions in the rate of reoperation for PJF at 12 months in a cohort of adult spinal deformity patients. The most dramatic reduction was seen among patients with lower thoracic UIV. These data suggest that in appropriately selected patients, ligament augmentation may be a valuable adjunct for PJF reduction; however, long-term follow-up is needed.

OBJECTIVE Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF. METHODS A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported. RESULTS A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2–4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01–1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01–1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05–3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility. CONCLUSIONS After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

Low back pain (LBP) is the leading cause of disability in the United States and the main reason for absenteeism. Successful management of chronic LBP (CLBP) is dependent on multimodal evidence-based interventions. Digital interventions (DI) may ease accessibility to such treatments, increasing adherence, while reducing healthcare-related costs.Assess the impact of a completely remote multimodal DI on productivity impairment in a real-work context cohort of patients with CLBP.Longitudinal study.Ad-hoc analysis of an interventional, single-arm study of individuals with CLBP undergoing a DI for 12 weeks. Outcomes included the mean change in work productivity and activity impairment (including overall and non-work related activities), pain, depression, anxiety, fear-avoidance beliefs, analgesic usage, and engagement. Minimal clinically important change (MCIC) was calculated for productivity using anchor- and distribution-based methods.From 560 patients at program start, 78.4% completed the DI. A significant improvement in overall productivity (20.21, 95%CI: 16.48-23.94) and in non-work related activities (21.36, 95%CI: 17.49-25.22) was observed, corresponding to a responder rate of 57.1-83.3% and 60.5-79.8%, respectively, and depending on the MCIC method. Significant improvements were reported for pain (2.32 points, 95%CI: 2.02-2.61), anxiety (5.24, 95%CI: 4.18-6.29), depression (6.38, 95%CI: 4.78-7.98) and fear-avoidance beliefs (8.11, 95%CI: 6.20-10.02). Both engagement (sessions per week) and patient satisfaction scores were high, 2.9 (SD 1.0) and 8.8/10 (SD 1.6), respectively.This study demonstrated the utility of a multimodal DI to address productivity impairment. DIs have great potential to ease the burden of CLBP, providing an accessible and cost-effective modality of care.The study was approved by the New England IRB (protocol number 120190313) and prospectively registered in ClinicalTrials.gov, NCT04092946, on September 17th, 2019.

OBJECTIVE Risk stratification is a critical element of surgical planning. Early tools were fairly crude, while newer instruments incorporate disease-specific elements and markers of frailty. It is unknown if discrepancies between chronological and cellular age can guide surgical planning or treatment. Telomeres are DNA-protein complexes that serve an important role in protecting genomic DNA. Their shortening is a consequence of aging and environmental exposures, with well-established associations with diseases of aging and mortality. There are compelling data to suggest that telomere length can provide insight toward overall health. The authors sought to determine potential associations between telomere length and postoperative complications. METHODS Adults undergoing elective surgery for spinal deformity were prospectively enrolled. Telomere length was measured from preoperative whole blood using quantitative polymerase chain reaction and expressed as the ratio of telomere (T) to single-copy gene (S) abundance (T/S ratio), with higher T/S ratios indicating longer telomere length. Demographic and patient data included age, BMI, and results for the following rating scales: the Adult Spinal Deformity Frailty Index (ASD-FI), Oswestry Disability Index (ODI), Scoliosis Research Society-22r (SRS-22r), American Society of Anesthesiology (ASA) classification, and Charlson Comorbidity Index (CCI). Operative and postoperative complication data (medical or surgical within 90 days) were also collected. RESULTS Forty-three patients were enrolled, including 31 women (53%), with a mean age of 66 years and a mean BMI of 28.5. The mean number of levels fused was 11, with 21 (48.8%) combined anterior-posterior approaches. Twenty-two patients (51.2%) had a medical or surgical complication. Patients with a postoperative complication had a significantly lower T/S ratio (0.712 vs 0.813, p = 0.008), indicating shorter telomere length, despite a mild difference in age compared with patients without a postoperative complication (68 vs 63 years, p = 0.069). Patients with complications also had higher CCI scores than patients without complications (2.3 vs 3.8, p = 0.004). There were no significant differences in sex, BMI, ASD-FI score, ASA class, preoperative ODI and SRS-22r scores, number of levels fused, or use of three-column osteotomies. In a multivariate model including age, frailty, ASA class, use of an anterior-posterior approach, CCI score, and telomere length, the authors found that short telomere length was significantly associated with postoperative complications. Patients whose telomere length fell in the shortest quartile had the highest risk (OR 18.184, p = 0.030). CONCLUSIONS Short telomere length was associated with an increased risk of postoperative complications despite only a mild difference in chronological age. Increasing comorbidity scores also trended toward significance. Larger prospective studies are needed; however, these data provide a compelling impetus to investigate the role of biological aging as a component of surgical risk stratification.

Background Fear-avoidance beliefs (FAB) have been associated with poorer prognosis and decreased adherence to exercise-based treatments in musculoskeletal (MSK) pain. However, the impact of high FAB on adherence and outcomes in upper extremity MSK (UEMSK) pain is poorly explored, particularly through exercise-based digital care programs (DCP). Objective Assess the adherence levels, clinical outcomes and satisfaction in patients with UEMSK pain and elevated FAB after a fully remote multimodal DCP. Associations between FABQ-PA and clinical outcomes were conducted. Methods Secondary analysis of an ongoing clinical trial. Participants with UEMSK pain (shoulder, elbow, and wrist/hand) and elevated FAB-physical activity (FABQ-PA ≥ 15) were included. Adherence (completion rate, sessions/week, total exercise time) and mean change in clinical outcomes—disability (QuickDASH), numerical pain score, FABQ-PA, anxiety (GAD-7), and depression (PHQ-9)—between baseline and end-of-program were assessed. Associations between FABQ-PA and clinical outcomes were conducted. Results 520 participants were included, with mean baseline FABQ-PA of 18.02 (SD 2.77). Patients performed on average 29.3 exercise sessions (2.8 sessions/week), totalizing 338.2 exercise minutes. Mean satisfaction was 8.5/10 (SD 1.7). Significant improvements were observed in all clinical outcomes. Higher baseline FAB were associated with higher baseline disability (P Conclusions This study provides evidence of the potential benefits of a structured and multimodal home-based DCP in the management of UEMSK pain conditions in patients with elevated FAB in a real-world context.

The influence of frailty on economic burden following corrective surgery for the adult cervical deformity (CD) is understudied and may provide valuable insights for preoperative planning.To assess the influence of baseline frailty status on the economic burden of CD surgery.Retrospective cohort.CD patients with frailty scores and baseline and two-year Neck Disability Index data were included. Frailty score was categorized patients by modified CD frailty index into not frail (NF) and frail (F). Analysis of covariance was used to estimate marginal means adjusting for age, sex, surgical approach, and baseline sacral slope, T1 slope minus cervical lordosis, C2-C7 angle, C2-C7 sagittal vertical axis. Costs were derived from PearlDiver registry data. Reimbursement consisted of a standardized estimate using regression analysis of Medicare payscales for services within a 30-day window including length of stay and death. This data is representative of the national average Medicare cost differentiated by complication/comorbidity outcome, surgical approach, and revision status. Cost per quality-adjusted life-year (QALY) at two years was calculated for NF and F patients.There were 126 patients included. There were 68 NF patients and 58 classified as F. Frailty groups did not differ by overall complications, instance of distal junctional kyphosis, or reoperations (all P0.05). These groups had similar rates of radiographic and clinical improvement by two years. NF and F had similar overall cost ($36,731.03 vs. $37,356.75, P =0.793), resulting in equivocal costs per QALYs for both patients at two years ($90,113.79 vs. $80,866.66, P =0.097).F and NF patients experienced similar complication rates and upfront costs, with equivocal utility gained, leading to comparative cost-effectiveness with NF patients based on cost per QALYs at two years. Surgical correction for CD is an economical healthcare investment for F patients when accounting for anticipated utility gained and cost-effectiveness following the procedure.III.

Study Design: Retrospective review of a multicenter prospective registry. Objectives: Our goal was to develop a method to risk-stratify adult spinal deformity (ASD) patients on the basis of their accumulated health deficits. We developed a novel comorbidity score (CS) specific to patients with ASD based on their preoperative health state and investigated whether it was associated with major complications, length of hospital stay (LOS), and self-reported outcomes after ASD surgery. Methods: We identified 273 operatively treated ASD patients with 2-year follow-up. We assessed associations between major complications and age, comorbidities, Charlson Comorbidity Index score, and Oswestry Disability Index score. Significant factors were used to construct the ASD-CS. Associations of ASD-CS with major complications, LOS, and patient-reported outcomes were analyzed. Results: Major complications increased significantly with ASD-CS ( P < .01). Compared with patients with ASD-CS of 0, the odds of major complications were 2.8-fold higher ( P = .068) in patients with ASD-CS of 1 through 3; 4.5-fold higher ( P < .01) in patients with ASD-CS of 4 through 6; and 7.5-fold higher ( P < .01) in patients with ASD-CS of 7 or 8. Patients with ASD-CS of 7 or 8 had the longest mean LOS (10.7 days) and worst mean Scoliosis Research Society–22r total score at baseline; however, they experienced the greatest mean improvement (0.98 points) over 2 years. Conclusions: The ASD-CS is significantly associated with major complications, LOS, and patient-reported outcomes in operatively treated ASD patients.

Multicenter database review of consecutive adult spinal deformity (ASD) patients.The aim of this study was to identify associations between changes in spinopelvic parameters and cervical alignment after thoracolumbar arthrodesis for ASD.Reciprocal cervical changes occur after instrumented thoracic spinal arthrodesis. The timing and relationship of these changes to sagittal alignment and upper instrumented vertebra (UIV) selection are unknown.In 171 ASD patients treated with thoracolumbar arthrodesis from 2008 to 2012, we assessed changes from baseline to 6-week, 1-year, and 2-year follow-up in C2-C7 sagittal vertical axis (SVA), T1 slope, and C2-C7 lordosis. We used multivariate models to analyze associations between these parameters and UIV selection (T9 or distal vs. proximal to T9) and changes at each time point in thoracic kyphosis (TK), lumbar lordosis (LL), C7-S1 SVA, pelvic incidence, pelvic tilt, and sacral slope.Two-year changes in C2-C7 SVA and T1 slope were significantly associated with baseline to 6-week changes in TK and LL and with UIV selection. Baseline to 2-year changes in C2-C7 lordosis were associated with baseline to 6-week changes in C7-S1 SVA (P = 0.004). Most changes in C2-C7 SVA occurred during the first 6 weeks postoperatively (mean 6-week change in C2-C7 SVA: 2.7 cm, 95% confidence interval [CI]: 0.7-4.7 cm; mean 2-year change in SVA: 2.3 cm, 95% CI: -0.1 to 4.6 cm). At 2 years, on average, there was decrease in C2-C7 lordosis, most of which occurred during the first 6 weeks postoperatively (mean 6-week change: -3.2°, 95% CI: -4.8° to -1.2°; mean 2-year change: -1.3°, 95% CI: - 3.2° to 0.5°).After thoracolumbar arthrodesis, reciprocal changes in cervical alignment are associated with postoperative changes in TK, LL, and C7-S1 SVA and with UIV selection. The largest changes occur during the first 6 weeks and persist during 2-year follow-up.3.

Proximal junctional kyphosis (PJK) is a widely recognized complication of adult spinal deformity surgery, and various PJK prevention strategies have been reported in recent years. The goal of the present study was to perform a systematic review of the PJK prevention strategies, report on their effectiveness, and delineate future directions for investigation regarding PJK prevention.A systematic review was conducted using PubMed, Embase, and Scopus to identify studies examining PJK prevention techniques. The titles and abstracts were screened, and those studies progressing to the full text review were screened using prespecified inclusion and exclusion criteria. The studies were organized thematically for analysis.The search identified a total of 382 studies, 23 of which were included. The overall quality of evidence was level III. The reported PJK prevention strategies included optimization of postoperative sagittal alignment by avoiding over- or undercorrection, prophylactic vertebral cement augmentation, the use of a transverse process hook at upper instrumented vertebra, the use of more flexible rod constructs, novel pedicle screw insertion techniques, the use of junctional tethers, and teriparatide therapy, which seemed to reduce the PJK rates.The reports of PJK prevention strategies were heterogeneous, and high-level evidence regarding any particular technique remains limited. Further development of additional PJK prevention techniques and validation of their efficacy in clinical practice are needed to optimize the outcomes of adult spinal deformity surgery.

Lumbosacral deformities are caused by high-grade spondylolisthesis, fractures, iatrogenic flat back, and other etiologies. The S1 pedicle subtraction osteotomy (PSO) can facilitate reduction of spondylolisthesis and lower the pelvic incidence. There are limited reports on the indications and outcomes of this technique.To present a technical description and literature review of the S1 PSO with video summary.This was a retrospective review of a single case to highlight the use of S1 PSO for the treatment of high-grade spondylolisthesis. A literature review was performed in accordance with STROBE guidelines.A 47-year-old woman presented with back and right leg pain related to grade 4 spondylolisthesis at L5-S1 with sagittal imbalance and lumbosacral kyphosis. She was taken for an L2-pelvis instrumented fusion with S1 PSO. Three days later, she was taken for an L4-5 and L5-S1 anterior lumbar interbody fusion with the L5-S1 segmental plate. Her postoperative course was notable for right foot drop that resolved in 6 weeks. Postoperative x-rays showed successful reduction of spondylolisthesis with normal alignment and sagittal balance. Based on 6 studies involving 22 true sacral PSOs in the literature, the procedure carries a 27% risk of neurological deficit, typically in the form of L5 palsy.The S1 PSO is a technically challenging operation that has a unique role in the treatment of high-grade spondylolisthesis. It carries a significant risk of L5 palsy and should be reserved for surgeons with experience performing complex 3-column osteotomies.

Author(s): Haddad, Alexander F; Scheer, Justin K; Fury, Marissa T; Smith, Justin S; Deviren, Vedat; Ames, Christopher P | Abstract: ObjectiveExtension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability.MethodsASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized.ResultsA total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p = 0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p = 0.022). ODI score was significantly higher in patients with scapular pain (p = 0.001). Chronic POSP (p = 0.001) and prior spine surgery (p = 0.037) were independently associated with ODI on multivariate analysis.ConclusionA UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.

The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a "good" versus a "bad" postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations.To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology.Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases.One hundred seventy spinal deformity patients.Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points.Operative deformity patients18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups.One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p = .020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p = .028). NRS Back pain differences between groups subsided by 2-years (p.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p .001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p .001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p = .060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p = .004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p = .039) and osteoporosis (adjusted beta: 0.269, p = .007) as the strongest predictors of a poor NRS back IHS (model summary: RDespite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear–avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear–avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

BACKGROUND CONTEXT With an aging population and increased prevalence of cervical deformity, corrective surgery is increasingly utilized as a treatment option. The goal of this study is to examine whether surgical advancements and expansion of knowledge over the years have improved or changed outcomes and the way we approach cervical deformity surgery. PURPOSE To investigate if outcomes or surgical approach have changed over time. STUDY DESIGN/SETTING Retrospective cohort study of a prospective adult cervical deformity (ACD) database. PATIENT SAMPLE This study included 119 ACD patients. OUTCOME MEASURES Complications after ACD surgery within 2 years, HRQL (NDI, mJOA, EQ5D) Methods ACD patients (≥18 years) with complete baseline and 2-year HRQL and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into Group I (2013-2014) and Group II (2015-2017) by DOS. Univariate, and multivariate analysis determined differences in surgical, radiographic, and clinical outcomes between groups. Results A total of 119 cervical deformity patients met inclusion criteria (61.3years, 67%F, BMI: 29kg/m2, CCI: 0.96±1.3). Radiographically at baseline, patients presented with: PT: 18.8± 11.3; PI: 53.0±11.1; PI-LL: -.45±17.7; SVA:-4.34±66.8, TS-CL: 38.1 ±21.4; cSVA: 45.2±25.6. Surgically, 51.3% had osteotomies, 47.1% had a posterior approach, 34.5% combined approach, 18.5% anterior approach, with 7.6± 3.8 levels fused and EBL of 824 mL. Group I consisted of 72 patients, and Group II consisted of 47. Group II had a higher CCI (1.3 vs .72), more cerebrovascular disease (6% vs 0%, both p 0.05). Controlling for baseline deformity and age, patients in Group II underwent fewer three-column osteotomies .17[.04-.8], (p 0.05). Additionally, controlling for levels fused and three-column osteotomies, Group II experienced fewer minor complications .3[.09-.96], (p Conclusions Despite operating on a higher risk cohort with more comorbidity, outcomes have remained consistent, indicating improvements in care. Surgically, there has been a reduction in the number of three-column osteotomies performed, suboptimal realignments, and fewer complications and adverse events. This suggests a better understanding of minimizing the risk of cervical deformity surgery with fewer invasive techniques. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. It is well established that patients benefit from such treatment; however, the surgical outcomes for patients with severe sagittal deformity have not been reported. OBJECTIVE To report the outcomes of patients undergoing surgical correction for severe sagittal deformity. METHODS Retrospective review of a prospective, multicenter ASD database. Inclusion criteria: operative patients age ≥18, sagittal vertical axis (SVA) ≥15 cm, mismatch between pelvic incidence and lumbar lordosis (PI-LL) ≥30°, and/or lumbar kyphosis ≥5° with minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores including minimal clinically important difference (MCID)/substantial clinical benefit (SCB), sagittal and coronal radiographic values, demographic, frailty, surgical, and complication data were collected. Comparisons between 2 yr postoperative and baseline HRQOL/radiographic data were made. P

Adult spinal deformity (ASD) is a complex and heterogeneous disease that can severely impact patients’ lives. While it is clear that surgical correction can achieve significant improvement of spinopelvic parameters and quality of life measures in adults with spinal deformity, there remains a high risk of complication associated with surgical approaches to adult deformity. Over the past decade, utilization of surgical correction for ASD has increased dramatically as deformity correction techniques have become more refined and widely adopted. Along with this increase in surgical utilization, there has been a massive undertaking by spine surgeons to develop more robust models to predict postoperative outcomes in an effort to mitigate the relatively high complication rates. A large part of this revolution within spine surgery has been the gradual adoption of predictive analytics harnessing artificial intelligence through the use of machine learning algorithms. The development of predictive models to accurately prognosticate patient outcomes following ASD surgery represents a dramatic improvement over prior statistical models which are better suited for finding associations between variables than for their predictive utility. Machine learning models, which offer the ability to make more accurate and reproducible predictions, provide surgeons with a wide array of practical applications from augmenting clinical decision making to more wide-spread public health implications. The inclusion of these advanced computational techniques in spine practices will be paramount for improving the care of patients, by empowering both patients and surgeons to more specifically tailor clinical decisions to address individual health profiles and needs.

Adult cervical deformity management is complex and is a growing field with many recent advancements. The cervical spine functions to maintain the position of the head and plays a pivotal role in influencing subjacent global spinal alignment and pelvic tilt as compensatory changes occur to maintain horizontal gaze. There are various types of cervical deformity and a variety of surgical options available. The major advancements in the management of cervical deformity have only been around for a few years and continue to evolve. Therefore, the goal of this article is to provide a comprehensive review of cervical alignment parameters, deformity classification, clinical evaluation, and surgical treatment of adult cervical deformity. The information presented here may be used as a guide for proper preoperative evaluation and surgical treatment in the adult cervical deformity patient.

To investigate the influence of surgeon specialty on 30-day postoperative complication rates for single-level lumbar discectomies.All patients who underwent single-level lumbar discectomy between 2005 and 2014 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Propensity score matching and univariate binary regression was used to determine whether surgeon subspecialty had an influence on 30-day postoperative complications.Of the 28,863 patients who underwent single-level lumbar discectomies during 2005-2014, 12,659 patients met inclusion criteria. Orthopedic surgeons performed 3733 operations (29.4%), and neurosurgeons performed 8926 operations (70.6%). A propensity-score matched sample of 7464 total cases (3732 orthopedic surgeon, 3732 neurosurgeon) was analyzed for the effect of surgeon specialty on 30-day outcomes. After propensity matching, orthopedic surgeons and neurosurgeons were similar in all postoperative outcomes, except for a slightly higher frequency of blood transfusions (0.3%, n = 11) in orthopedic versus neurosurgery patients (0.1%, n = 3; P = 0.032), although this did not remain significant after Bonferroni adjustment. Mean operative time was slightly longer for neurosurgeons (83.7 minutes) versus orthopedic surgeons (72.5 minutes; P0.001). There were no significant differences in mortality, readmission, or reoperation rates.Single-level lumbar discectomies hold a low complication profile and show equivalent outcomes for both orthopedic and neurological surgeons, although neurosurgeons may exhibit a slightly longer mean operative time. In propensity score-matched cohorts, orthopedic surgeons had slightly higher rates of blood transfusions, although the number was small and did not remain significant after Bonferroni adjustment.

Retrospective review of prospective multicenter adult spinal deformity (ASD) database.To compare the quality-adjusted life years (QALYs) between operative and nonoperative treatments for ASD patients.Operative management of ASD repeatedly demonstrates improvements in HRQOL over nonoperative treatment. However, little is reported regarding QALY improvements after surgical correction of ASD.Inclusion criteria: ≥18 years, ASD. Health utility values were calculated from SF6D scores and used to calculate QALYs at minimum 2 years from the baseline utility value as well as at 1, 2, and 3 years for the available patients. A 1:1 propensity score matching using six baseline variables was conducted to account for the nonrandom distribution of operative and nonoperative treatments.Four hundred seventy-nine patients were included (OP:258, 70.7%, NONOP:221, 47.1%). One hundred fifty-one (OP:90, NONOP:61) had complete 1, 2, and 3 year data available for QALY trending. Unmatched results are not listed in the abstract. Mean baseline utility scores were statistically similar between the matched groups (OP: 0.609 ± 0.093, NONOP: 0.600 ± 0.091, P = 0.6401) and at 2 year min postop mean OP QALY was greater than NONOP (1.377 ± 0.345 vs. 1.256 ± 0.286, respectively, P 0.01). For the subanalysis cohort, mean OP QALYs at 1, 2, and 3 years postoperative were all significantly greater than NONOP, P 0.03 for all (1 yr: 0.651 ± 0.089 vs. 0.61 ± 0.079, 2 yr: 1.29 ± 0.157 vs. 1.189 ± 0.141, and 3 yr: 1.903 ± 0.235 vs. 1.749 ± 0.198, respectively). Matched OP had a larger QALYs gained (from baseline) at 2 year minimum postoperative (0.112 ± 0.243 vs. 0.008 ± 0.195, P 0.01). For subanalysis of patients with complete 1 to 3 years data, OP had a significantly larger QALYs gained at 1, 2, and 3 years compared with NONOP: 1 year (0.073 ± 0.121 vs. 0.029 ± 0.082, P = 0.0447), 2 years (0.167 ± 0.232 vs. 0.036 ± 0.173, P = 0.0030), and 3years (0.238 ± 0.379 vs. 0.059 ± 0.258, P 0.01).The operative treatment of adult spinal deformity results in significantly greater mean QALYs and QALYs gained at minimum 2 years postop as well as at the 1-, 2-, and 3-year time points compared with nonoperative management.3.

BACKGROUND Surgical treatments for adult cervical spinal deformity (ACSD) are often complex and have high complication rates. OBJECTIVE To assess all-cause mortality following ACSD surgery. METHODS ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Clinical and surgical parameters and all-cause mortality were assessed. RESULTS Of 123 ACSD patients, 120 (98%) had complete baseline data (mean age, 60.6 yr). The mean number of comorbidities per patient was 1.80, and 80% had at least 1 comorbidity. Surgical approaches included anterior only (15.8%), posterior only (50.0%), and combined anterior/posterior (34.2%). The mean number of vertebral levels fused was 8.0 (standard deviation [SD] = 4.5), and 23.3% had a 3-column osteotomy. Death was reported for 11 (9.2%) patients at a mean of 1.1 yr (SD = 0.76 yr; range = 7 d to 2 yr). Mean follow-up for living patients was 1.2 yr (SD = 0.64 yr). Causes of death included myocardial infarction (n = 2), pneumonia/cardiopulmonary failure (n = 2), sepsis (n = 1), obstructive sleep apnea/narcotics (n = 1), subsequently diagnosed amyotrophic lateral sclerosis (n = 1), burn injury related to home supplemental oxygen (n = 1), and unknown (n = 3). Deceased patients did not significantly differ from alive patients based on demographic, clinical, or surgical parameters assessed, except for a higher major complication rate (excluding mortality; 63.6% vs 22.0%, P = .006). CONCLUSION All-cause mortality at a mean of 1.2 yr following surgery for ACSD was 9.2% in this prospective multicenter series. Causes of death were reflective of the overall high level of comorbidities. These findings may prove useful for treatment decision making and patient counseling in the context of the substantial impact of ACSD.

Objective To determine the value of a novel adult cervical deformity frailty index (CD-FI) in preoperative risk stratification. Methods We reviewed a prospective, multicenter database of adults with cervical spine deformity. We selected 40 variables to construct the CD-FI using a validated method. Patients were categorized as not frail (NF) ( 0.4) according to CD-FI score. We performed multivariate logistic regression to determine the relationships between CD-FI score and incidence of complications, length of hospital stay, and discharge disposition. Results Of 61 patients enrolled from 2009 to 2015 with at least 1 year of follow-up, the mean CD-FI score was 0.26 (range 0.25–0.59). Seventeen patients were categorized as NF, 34 as frail, and 10 as SF. The incidence of major complications increased with greater frailty, with a gamma correlation coefficient of 0.25 (asymptotic standard error, 0.22). The odds of having a major complication were greater for frail patients (odds ratio 4.4; 95% confidence interval 0.6–32) and SF patients (odds ratio 43; 95% confidence interval 2.7–684) compared with NF patients. Greater frailty was associated with a greater incidence of medical complications and had a gamma correlation coefficient of 0.30 (asymptotic standard error, 0.26). Surgical complications, discharge disposition, and length of hospital stay did not correlate significantly with frailty. Conclusions Greater frailty was associated with greater risk of major complications for patients undergoing cervical spine deformity surgery. The CD-FI may be used to improve the accuracy of preoperative risk stratification and allow for adequate patient counseling.

BACKGROUND Despite the potential for profound impact of adult cervical deformity (ACD) on function and health-related quality of life (HRQOL), there are few high-quality studies that assess outcomes of surgical treatment for these patients. OBJECTIVE To determine the impact of surgical treatment for ACD on HRQOL. METHODS We conducted a prospective cohort study of surgically treated ACD patients eligible for 1-yr follow-up. Baseline deformity characteristics, surgical parameters, and 1-yr HRQOL outcomes were assessed. RESULTS Of 77 ACD patients, 55 (71%) had 1-yr follow-up (64% women, mean age of 62 yr, mean Charlson Comorbidity Index of 0.6, previous cervical surgery in 47%). Diagnoses included cervical sagittal imbalance (56%), cervical kyphosis (55%), proximal junctional kyphosis (7%) and coronal deformity (9%). Posterior fusion was performed in 85% (mean levels = 10), and anterior fusion was performed in 53% (mean levels = 5). Three-column osteotomy was performed in 24% of patients. One year following surgery, ACD patients had significant improvement in Neck Disability Index (50.5 to 38.0, P < .001), neck pain numeric rating scale score (6.9 to 4.3, P < .001), EuroQol 5 dimension (EQ-5D) index (0.51 to 0.66, P < .001), and EQ-5D subscores: mobility (1.9 to 1.7, P = .019), usual activities (2.2 to 1.9, P = .007), pain/discomfort (2.4 to 2.1, P < .001), anxiety/depression (1.8 to 1.5, P = .014). CONCLUSION Based on a prospective multicenter series of ACD patients, surgical treatment provided significant improvement in multiple measures of pain and function, including Neck Disability Index, neck pain numeric rating scale score, and EQ-5D. Further follow-up will be necessary to assess the long-term durability of these improved outcomes.

A systematic review.The available literature on interspinous rigid fixation/fusion devices (IFD) was systematically reviewed to explore the devices' efficacy and complication profile.The clinical application of new spinal technologies may proceed without well-established evidence, as is the case with IFDs. IFDs are plate-like devices that are attached to the lateral aspects of 2 adjacent spinous processes to promote rigidity at that segment. Despite almost a decade since the devices' introduction, the literature regarding efficacy and safety is sparse. Complications have been reported but no definitive study is known to the authors.A systematic review of the past 10 years of English literature was conducted according to PRISMA guidelines. The timeframe was chosen based on publication of the first study containing a modern IFD, the SPIRE, in 2006. All PubMed publications containing MeSH headings or with title or abstract containing any combination of the words "interspinous," "spinous process," "fusion," "fixation," "plate," or "plating" were included. Exclusion criteria consisted of dynamic stabilization devices (X-Stop, DIAM, etc.), cervical spine, pediatrics, and animal models. The articles were blinded to author and journal, assigned a level of evidence by Oxford Centre of Evidence-Based Medicine (OCEBM) criteria, and summarized in an evidentiary table.A total of 293 articles were found in the initial search, of which 15 remained after examination for exclusion criteria. No class I or class II evidence regarding IFDs was found. IFDs have been shown by methodologically flawed and highly biased class III evidence to reduce instability at 1 year, without statistical comparison of complication rates against other treatment modalities.Although IFDs are heavily marketed and commonly applied in modern practice, data on safety and efficacy are inadequate. The paucity of evidence warrants reexamination of these devices' value and indications by the spine surgery community.

BACKGROUND CONTEXT As operative measures and field knowledge advance, we hope that there is an improvement in outcomes for adult cervical deformity surgery. This improvement can be described by cost effectiveness, which encompasses operative cost, poor outcomes such as complications, and patient-reported measures. PURPOSE To determine whether surgical methods have improved by reducing the instance of complications and cost of cervical deformity (CD) surgery while improving patient reported outcomes. STUDY DESIGN/SETTING Retrospective cohort study of a prospectively enrolled multicenter CD database. PATIENT SAMPLE A total of 132 CD patients. OUTCOME MEASURES Complications, Reoperations, EQ5D, total cost, utility gained, Quality Adjusted Life Years (QALYs), Distal Junctional Kyphosis (DJK) METHODS CD patients with baseline (BL) and up to 2-year (2Y) HRQL data from 2013-2017 were included. Data from 2017 was combined with 2016 due to an incomplete year. ANCOVA found estimated marginal means of complications and reoperations adjusting for BL age, sex, surgical approach, and invasiveness. Cost was calculated using PearlDiver and assessed for Complications/Major Complications and Comorbidities according to CMS.gov. QALYs were calculated from EQ5D improvement and utilized 3% discount rate for residual decline to life expectancy (LE, 78.7 years). This data represents national average Medicare costs by surgical approach, complications and revision status. Trendline analysis noted changes over time. In a sub-analysis relating to a previous study, patients were identified by amount of risk factors for revision (UIV>C3, LIV>T3, C2-T3 SVA 57.6°, CTPA>7.8°, and C2S RESULTS There were 132 patients included in the study. Of these, 24 had surgery in 2013, 52 in 2014, 24 in 2015, and 32 in 2016. There was a trend downward with respect to 2-year total cost over the years (2013: $42,754; 2016: $39,155), as the trendline showed a yearly decrease of $2,753 (R2=0.6966). Concurrently, there was an increase EQ5D improvement after 2-year (2013: 0.0113; 2016: 0.0697). This resulted in an increase of 0.0172 per year in QALYs gained at 2-year (R2=0.8109) and a 0.2358 increase per year in QALYs gained at LE (R2=0.8533). Thus, there was a decrease in cost per QALY at 2-year of $6,057 per year (R2=0.0497) and at LE of $67,478 per year (R2=06588). Total cost at 2-year for those with Distal Junctional Kyphosis was $98,357 vs $59,129 for non-DJK; cost per QALY was $46,932 vs $28,571, respectively. Sub-analysis indicated increasing risk criteria were associated with major complications (2.085 [1.057-4.114], p=0.034) and reoperations (4.267 [1.604-11.352], p=0.004). Cost increased by $7,167 per factor (R2=0.9901). Patients with fewer factors had greater NDI improvement than high risk (1: -24.6; 2: -14.8; 3: -15.6; 4: -3.8, p=0.023). This translated to low cost per QALY at 2-year for 1 factor ($45,787), with worse cost efficiency per factor (2: $90,117; 3: $103,543; 4: $525,472). CONCLUSIONS Between 2013 and 2017, total cost for cervical deformity surgery decreased – possibly due to complication and risk reductions – while EQ5D improvement has increased, leading to improved cost effectiveness. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

This is a retrospective review of a prospective multicenter adult spinal deformity (ASD) database.To quantify the location and magnitude of sagittal alignment changes within instrumented and noninstrumented spinal segments and to investigate the factors associated with these changes after surgery for ASD.Spinal realignment is one of the major goals in ASD surgery and changes in the alignment are common following surgical correction.Inclusion criteria: operative patients with age above 18, coronal Cobb angle ≥20 degrees, sagittal vertical axis (SVA) ≥5 cm, pelvic tilt ≥25 degrees, and/or thoracic kyphosis ≥60 degrees.revision surgery 6 weeks postoperatively. Standard sagittal radiographic spinal deformity parameters were evaluated. Changes in sagittal parameters between 6 weeks and 2 years postoperatively were assessed within and outside instrumented segments. Associations between changes in sagittal alignment and age, preoperative SVA, rod diameters, rod material, presence of 3-column osteotomy, and the use of interbody fusions were evaluated. Patients were also stratified by5- and10-degree changes in alignment.In total, 183 patients (male:29, female:154, average age: 56±14.8 y) met inclusion criteria. A total of 45(24.6%) patients had increase in pelvic tilt5 degrees, 74(40.4%) had increase in pelvic incidence and lumbar lordosis (LL)5 degrees, and 76 (41.5%) had increase in SVA2 cm. Mean change of thoracic sagittal alignment was +8 degrees; 70 (60%) patients had increases of5 degrees and 31 (27%) had increases of10 degrees. Noninstrumented thoracic segments had significantly more increase than instrumented thoracic segments (P=0.02). Mean loss of LL was -6 degrees; 49(47%) patients had worsening5 degrees and 13(13%)10 degrees. Noninstrumented lumbar segments had significantly less loss of lordosis than instrumented segments (P0.01). Risks for loss of LL were: age 65 years and above [odds ratio (OR) 9.4; 95% confidence interval (CI), 3.5-25.2; P0.01], preoperative SVA5 cm (OR, 2.4; 95% CI, 1.3-4.4; P0.01), and lumbar interbody fusion (OR, 2.3; 95% CI, 1.2-4.2; P0.01). Smaller rods (4.5 mm) were associated with a lower probability of worsening LL compared with 5.5-mm rods (OR, 0.15; 95% CI, 0.04-0.58; P0.01) and 6.0-mm rods (OR, 0.36; 95% CI, 0.18-0.72; P0.01). The presence of a 3-column osteotomy and rod material were not significant factors in alignment changes (P0.05).After correction of ASD, increases in thoracic and decreases in lumbar alignment is common. Loss of thoracic sagittal alignment primarily occurs in noninstrumented thoracic segments, whereas instrumented lumbar levels in elderly patients ( above 65 y) with high preoperative SVA, interbody fusions, and larger rods have significantly higher rates of postoperative sagittal alignment changes in the lumbar spine.