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Background: Early-term complications may not predict long-term success after adult cervical deformity (ACD) correction., Objective: Evaluate whether optimal realignment results in similar rates of perioperative complications but achieves longer-term cost-utility., Study Design: Retrospective cohort study., Methods: ACD patients with 2-year data included. Outcomes: distal junctional failure (DJF), good clinical outcome (GCO):[Meeting 2 of 3: (1) NDI>20 or meeting MCID, (2) mJOA≥14, (3)NRS-Neck improved≥2]. Ideal Outcome defined as GCO without DJF or reoperation. Patient groups were stratified by correction to 'Optimal radiographic outcome', defined by cSVA 9 (<40 mm) AND TS-CL (<15 deg) upon correction. Cost calculated by CMS.com definitions, and cost-per-QALY was calculated by converting NDI to SF-6D. Multivariable analysis controlling for age, baseline T1-slope, cSVA, disability, and frailty, was used to assess complication rates, clinical outcomes, and cost-utility based on meeting optimal radiographic outcome., Results: One hundred forty-six patients included: 52 optimal radiographic realignment (O) and 94 not optimal (NO). NO group presented with higher cSVA and T1-slope. Adjusted analysis showed O group suffered similar 90-day complications (P>0.8), but less DJK, DJF (0% vs. 18%; P<0.001) and reoperations (18% vs. 35%; P=0.02). Patients meeting optimal radiographic criteria more often met Ideal outcome [odds ratio: 2.2, (1.1-4.8); P=0.03]. Despite no differences in overall cost, O group saw greater clinical improvement, translating to a better cost-utility [mean difference: $91,000, ($49,000-$132,000); P<0.001]., Conclusion: Despite similar perioperative courses, patients optimally realigned experienced less junctional failure, leading to better cost-utility compared with those sub-optimally realigned. Perioperative complication risk should not necessarily preclude optimal surgical intervention, and policy efforts might better focus on long-term outcome measures in adult cervical deformity surgery., Level of Evidence: Level III., Competing Interests: P.G.P. Allosource: Other financial or material support Cervical Scoliosis Research Society: Research support Globus Medical: Paid presenter or speaker Medtronic: Paid consultant Royal Biologics: Paid consultant Spine: Editorial or governing board SpineWave: Paid consultant Terumo: Paid consultant Zimmer: Paid presenter or speaker. V.L. DePuy, A Johnson & Johnson Company: Paid presenter or speaker European Spine Journal: Editorial or governing board Globus Medical: Paid consultant International Spine Study Group: Board or committee member Nuvasive: IP royalties Scoliosis Research Society: Board or committee member The Permanente Medical Group: Paid presenter or speaker. R.L. Nemaris: Stock or stock Options. R.K.E., MD Aesculap/B.Braun: Paid consultant Alphatec Spine: Stock or stock Options Baxter: Paid consultant Biedermann-Motech: Paid consultant Carevature: Paid consultant; Stock or stock Options Globus Medical: IP royalties Invuity: Stock or stock Options Medtronic: Paid consultant Nocimed: Stock or stock Options Nuvasive: IP royalties; Paid consultant; Research support; Stock or stock Options Radius: Paid presenter or speaker San Diego Spine Foundation: Board or committee member Scoliosis Research Society: Board or committee member Seaspine: IP royalties; Paid consultant; Stock or stock Options SI Bone: IP royalties; Paid consultant Society of Lateral Access Surgery: Board or committee member Spine Innovations: Stock or stock Options Stryker: Paid consultant. A.J.S. AAOS: Board or committee member Journal of Bone and Joint Surgery—American: Editorial or governing board North American Spine Society: Board or committee member Spine: Editorial or governing board Springer: Publishing royalties, financial or material support Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties, financial or material support. L.A.T. Medtronic: Paid consultant Stryker: Paid consultant. T.B. ISSGF—Research support, NuVasive – Research support, Operative Neurosurgery— Editorial Board, Spine Deformity—Editorial Board. The remaining authors declare no conflict of interest., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recent studies highlight the increasing adoption of single-position prone lateral(SP-PL) and single-position lateral decubitus(SP-LD) in Minimally Invasive Spine Surgery(MISS) to reduce operative time, enhance patient safety, and improve surgical accessibility., Objective: To assess the differences between SP-PL and SP-LD achievement of optimal postoperative outcomes and post-operative complication rates., Study Design: Retrospective review of prospectively collected MIS database., Methods: Consecutive series of 152 Patients with baseline(BL) and 1-year(1Y) postoperative radiographic/HRQL data were included. Patients placed in the SP-PL or SP-LD were isolated. Optimal Outcome(OO) was defined as patients who experienced no complication requiring reoperation and achieved Substantial Clinical Benefit(SCB) for NRS-leg or NRS-back. Means comparison analysis assessed differences in radiographic and clinical outcomes. ANCOVA and multivariable backward stepwise logistic regression were used to adjust for confounders., Results: 59 SP-PL and 93 SP-LD patients were included. At baseline, cohorts were comparable in terms of age, gender, BMI, and CCI. Peri-operatively, SP-PL patients had a significantly lower operative time(207.22 vs. 317.5 min;P<0.001), LOS(3.1 vs. 3.6 days;P=0.033), EBL(244.5 vs. 376.3 mL;P=0.023), and demonstrated lower perioperative complication rate(25.4% vs. 41.9%;P=0.038). Multivariable analysis indicated that SP-PL patients had a lower likelihood of cardiac perioperative complications(OR 0.012;CI95%: 0.0-0.6;P=0.026). Immediate postoperatively, SP-PL has a greater degree of segmental lordosis improvement from L1-L2 to L5-S1(all;P<0.05). SP-PL patients have a higher likelihood of achieving SCB NRS-Back at 1Y(OR: 8.0;CI95%: 1.5-42.0;P=0.014) and MCID NRS-leg at 1Y(OR:4.6;CI95%:1.002-21.2;P=0.49). The SP-PL cohort had a significantly greater percentage of OO(96.6% vs. 78.5%;P=0.002) and a higher likelihood of achieving OO in adjusted analysis (OR:10.6;CI95%: 2.1-53.3;P=0.004)., Conclusions: Patients placed in the SP-PL during minimally invasive spine surgery exhibit a reduced rate of perioperative complications, higher incidence of SCB, and a superior rate of achieving optimal outcome at the one-year follow-up. These findings underscore the SP-PL position as a potentially advantageous approach for minimally invasive lumbar fusion., Competing Interests: Conflicts of Interest related to current work: Peter Gust Passias, MD. Allosource: Other financial or material support. Cervical Scoliosis Research Society: Research support. Globus Medical: Paid presenter or speaker. Medtronic: Paid consultant. Royal Biologics: Paid consultant. Spine: Editorial or governing board. SpineWave: Paid consultant. Terumo: Paid consultant. Zimmer: Paid presenter or speaker. Andrew J Schoenfeld, MD. AAOS: Board or committee member. Journal of Bone and Joint Surgery - American: Editorial or governing board. North American Spine Society: Board or committee member. Spine: Editorial or governing board. Springer: Publishing royalties, financial or material support. Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support. Christopher I Shaffrey, MD. AANS: Board or committee member. Cervical Spine Research Society: Board or committee member. DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Research support. Globus Medical: Research support. Medtronic: Other financial or material support; Paid consultant. Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Research support. Neurosurgery RRC: Board or committee member. Nuvasive: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Stock or stock Options Proprio: Paid consultant. Scoliosis Research Society: Board or committee member. SI Bone: IP royalties. Spinal Deformity: Editorial or governing board. Spine: Editorial or governing board. Muhammad M. Abd-El-Barr, MD, PhD. Consultant for Spineology, Depuy Synthes, TrackX, and Spinal Elements.. Receives research support from the NIH, Abbvie, and the Dana and Christopher Reeve Foundation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: To compare degrees of cSVA correction and to theorize possible minimum and maximum thresholds of cSVA correction for patients to benefit clinically., Methods: 657 operative ACD patients in a retrospective cohort study of a prospectively enrolled database with complete baseline and two year radiographic and HRQL data were examined. Patients were grouped into an optimally corrected cohort (OC; postop cSVA ≤ 4 cm) and an undercorrected cohort (UC; postop cSVA > 4 cm) based on postoperative radiographs., Results: 265 patients met inclusion criteria (mean age 58.2 ± 11.4 years, BMI 28.9 ± 7.5, CCI 0.9 ± 1.3). 11.2 % of patients were UC, while 88.8 % of patients were OC. UC cohort experienced a significantly greater occurrence of radiographic complications (47.8 % v. 27.6 %, p = 0.046). UC also demonstrated a significantly greater rate of severe 6 M DJK (p < 0.001) and 1Y DJK (26.1 % v. 2.7 %, p < 0.001). In terms of HRQLs, the OC cohort demonstrated significantly greater 2Y EQ5D-Health values (76.9 v. 46.7, p = 0.012). Being UC was a significant predictor of moderate-high 1Y mJOA score (OR 3.0, CI 95 % 1.2-7.3, p = 0.015) Still, in terms of CIT, the threshold for DJF risk increased significantly (p = 0.026) when the cSVA were surgically corrected greater than 5 cm., Conclusion: Undercorrection of cSVA yielded worse clinical outcomes and posed a significant risk for radiographic complications. Although undercorrection does not seem to be efficacious, surgical correction beyond certain thresholds should still be respected as there is a risk for DJK on either end of the spectrum., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: The association of Hounsfield units (HU) and junctional pathologies in adult cervical deformity (ACD) surgery has not been elucidated., Objective: Assess if the bone mineral density of the LIV, as assessed by HUs, is prognostic for the risk of complications after ACD surgery., Study Design/setting: Retrospective cohort study., Methods: HUs were measured on preoperative CT scans. Means comparison test assessed differences in HUs based on the occurrence of complications, linear regression assessed the correlation of HUs with risk factors, and multivariable logistic regression followed by a conditional inference tree derived a threshold for HUs based on the increased likelihood of developing a complication., Results: In all, 107 ACD patients were included. Thirty-one patients (29.0%) developed a complication (18.7% perioperative), with 20.6% developing DJK and 11.2% developing DJF. There was a significant correlation between lower LIVs and lower HUs ( r =0.351, P =0.01), as well as age and HUs at the LIV. Age did not correlate with change in the DJK angle ( P >0.2). HUs were lower at the LIV for patients who developed a complication and an LIV threshold of 190 HUs was predictive of complications (OR: 4.2, [1.2-7.6]; P =0.009)., Conclusions: Low bone mineral density at the lowest instrumented vertebra, as assessed by a threshold lower than 190 Hounsfield units, may be a crucial risk factor for the development of complications after cervical deformity surgery. Preoperative CT scans should be routinely considered in at-risk patients to mitigate this modifiable risk factor during surgical planning., Level of Evidence: Level-III., Competing Interests: P.G.P.— Allosource: Other financial or material support; Cervical Scoliosis Research Society: Research support; Globus Medical: Paid presenter or speaker; Medtronic: Paid consultant; Royal Biologics: Paid consultant; Spine: Editorial or governing board; SpineWave: Paid consultant; Terumo: Paid consultant; Zimmer: Paid presenter or speaker. R.L. —Nemaris: Stock or stock Options. A.J.S.— AAOS: Board or committee member; Journal of Bone and Joint Surgery - American: Editorial or governing board; North American Spine Society: Board or committee member; Spine: Editorial or governing board; Springer: Publishing royalties, financial or material support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support. V.L.— DePuy, A Johnson & Johnson Company: Paid presenter or speaker; European Spine Journal: Editorial or governing board; Globus Medical: Paid consultant; International Spine Study Group: Board or committee member; Nuvasive: IP royalties; Scoliosis Research Society: Board or committee member; The Permanente Medical Group: Paid presenter or speaker. The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: None of the authors of this manuscript report any competing interests.

Background: Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described., Study Design/setting: This is a retrospective study on a prospectively enrolled, complex ASD database., Purpose: This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications., Methods: Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO., Results: 648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m 2 , levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086)., Conclusion: Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background/Objectives: Comparative studies often use the p value to convey statistical significance, but fragility indices (FI) and fragility quotients (FQ) may better signify statistical strength. The use of aspirin as venous thromboembolism (VTE) chemoprophylaxis following elective arthroplasty has been debated between the orthopedic and cardiac fields. The purpose of this study was to apply both the FI and FQ to evaluate the degree of statistical fragility in the total joint arthroplasty (TJA) literature regarding aspirin (ASA) use for VTE prevention. Methods: We performed a systematic search for TJA clinical trials from 2004 to 2023 reporting comparisons between ASA and other chemoprophylaxis methods for VTE. The FI of each outcome was calculated through reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each fragility index by study sample size and interquartile range (IQR) was calculated. SPSS Meta-analysis function was used to calculate the Mean Effect Size Estimate and 95% Confidence Intervals for each outcome. Results: Of 245 articles screened, 39 met search criteria, with 10 RCTs included for analysis (n = 11,481 patients). There were 38 outcome events reported, with three significant ( p < 0.05) outcomes and 35 non-significant ( p > 0.05) outcomes identified. The overall FI and FQ for all 38 outcomes were 6 (IQR: 5-7) and 0.059 (IQR: 0.044-0.064), respectively. Seven studies (70%) reported a loss-to-follow-up (LTF) greater than the overall FI. There was no increased risk of DVT, PE, or mortality with use of ASA (all p > 0.2). Conclusions: Despite showing non-inferiority in preventing venous thromboembolic events in TJA overall, the highest-level peer-reviewed literature concerning aspirin use following total joint arthroplasty is considered statistically fragile due to high loss-to-follow-up. In addition to the reporting of the p value, the fragility index and quotient can further provide insight into the strength and trustworthiness of outcome measures.

Study Design: Retrospective cohort study., Purpose: To determine the incidence and success of three-column osteotomies (3COs) performed in primary and revision adult spine deformity (ASD) corrective surgeries., Overview of Literature: 3COs are often required to correct severe, rigid ASD presentations. However, controversy remains on the utility of 3COs, particularly in primary surgery., Methods: Patients ASD having 2-year data were included and divided into 3CO and non-3CO (remaining ASD cohort) groups. For the subanalysis, patients were stratified based on whether they were undergoing primary (P3CO) or revision (R3CO) surgery. Multivariate analysis controlling for age, Charlson comorbidity index, body mass index, baseline pelvic incidence-lumbar lordosis, and fused levels evaluated the complication rates and radiographic and patient-reported outcomes between the 3CO and non-3CO groups., Results: Of the 436 patients included, 20% had 3COs. 3COs were performed in 16% of P3COs and 51% of R3COs. Both 3CO groups had greater severity in deformity and disability at baseline; however, only R3COs improved more than non-3COs. Despite greater segmental correction, 3COs had much lower rates of aligning in the lumbar distribution index (LDI), higher mechanical complications, and more reoperations when performed below L3. When comparing P3COs and R3COs, baseline lumbopelvic and global alignments, as well as disability, were different. The R3CO group had greater clinical improvements and global correction (both p<0.04), although the P3CO group achieved alignment in LDI more often (odds ratio, 3.9; 95% confidence interval, 1.3-6.2; p=0.006). The P3CO group had more neurological complications (30% vs. 13%, p=0.042), whereas the R3CO tended to have higher mechanical complication rates (25% vs. 15%, p=0.2)., Conclusions: 3COs showed greater improvements in realignment while failing to demonstrate the same clinical improvement as primaries without a 3CO. Overall, when suitably indicated, a 3CO offers superior utility for achieving optimal realignment across primary and revision surgeries for ASD correction.

Summary of Background Data: Yilgor et al developed the lumbar Lordosis Distribution Index to individualize the pelvic mismatch to each patient's pelvic incidence. The cervical lordosis distribution in relation to its apex has not been characterized., Objective: Tailor correction of cervical deformity by incorporating the cervical apex into a distribution index(CLDI) to maximize clinical outcomes while lowering rates of junctional failure., Study Design/setting: Retrospective cohort., Methods: CD patients with complete 2Y data were included. Optimal outcome is defined by no DJF, and meeting Virk et al Good Clinical Outcome Criteria:[Meeting 2 of 3: 1)an NDI<20 or meeting MCID, 2)mJOA>=14, 3)an NRS-Neck<=5 or improved by 2 or more points]. C2-T2 lordosis was divided into cranial (C2 to apex) and caudal (apex to T2) arches postoperatively. A cervical lordosis distribution index(CLDI) was developed by dividing the cranial lordotic arch(C2 to apex) by the total segment(C2-T2) and multiplying by 100. Cross-tabulations developed categories for CLDI producing the highest chi-square values for achieving Optimal Outcome at two years and outcomes were assessed by multivariable analysis controlling for significant confounders., Results: 84 CD patients were included. Cervical apex distribution postoperatively was: 1% C3, 42% C4, 30% C5, 27% C6. Mean cervical LDI was 117±138. Mean cranial lordosis was 23.2±12.5°. Using cross-tabulations, a CLDI between 70 and 90 was defined as 'Aligned'. Chi-square test revealed significant differences among CLDI categories for DJK, DJF, Good Clinical Outcome, and Optimal Outcome(all P<0.05). Patients aligned in CLDI were less likely to develop DJK(OR: 0.1, [0.01-0.88]), more like to achieve GCO (OR: 3.9, [1.2-13.2]) and Optimal Outcome (OR: 7.9, [2.1-29.3] at two years. Patients aligned in CLDI developed DJF at a rate of 0%., Conclusion: The cervical lordosis distribution index, classified through the cranial segment, takes each unique cervical apex into account and tailors correction to the patient in order to better achieve good clinical outcomes and minimize catastrophic complications following cervical deformity surgery., Level of Evidence: III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery., Methods: Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups., Results: A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9)., Conclusions: There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has not shown superior benefit overall in cost-effectiveness during adult spinal deformity (ASD) surgery., Study Design/setting: Retrospective PURPOSE: Generate a risk score for pseudarthrosis to inform the utilization of rhBMP-2, balancing costs against quality of life and complications., Methods: ASD patients with 3-year data were included. Quality of life gained was calculated from ODI to SF-6D and translated to quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions for complications and comorbidities. Established weights were generated for predictive variables via logistic regression to yield a predictive risk score for pseudarthrosis that accounted for frailty, diabetes, depression, ASA grade, thoracolumbar kyphosis and three-column osteotomy use. Risk score categories, established via conditional inference tree (CIT)-derived thresholds were tested for cost-utility of rhBMP-2 usage, controlling for age, prior fusion, and baseline deformity and disability., Results: 64% of ASD patients received rhBMP-2 (308/481). There were 17 (3.5%) patients that developed pseudarthrosis. rhBMP-2 use overall did not lower pseudarthrosis rates (OR: 0.5, [0.2-1.3]). Pseudarthrosis rates for each risk category were: No Risk (NoR) 0%; Low-Risk (LowR) 1.6%; Moderate Risk (ModR) 9.3%; High-Risk (HighR) 24.3%. Patients receiving rhBMP-2 had similar QALYs overall to those that did not (0.163 vs. 0.171, p = .65). rhBMP-2 usage had worse cost-utility in the LowR cohort (p < .001). In ModR patients, rhBMP-2 usage had equivocal cost-utility ($53,398 vs. $61,581, p = .232). In the HighR cohort, the cost-utility was reduced via rhBMP-2 usage ($98,328 vs. $211,091, p < .001)., Conclusion: Our study shows rhBMP-2 demonstrates effective cost-utility for individuals at high risk for developing pseudarthrosis. The generated score can aid spine surgeons in the assessment of risk and enhance justification for the strategic use of rhBMP-2 in the appropriate clinical contexts., Level of Evidence: III., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Many orthopaedic surgeons routinely prescribe aspirin (ASA) as prophylaxis for venous thromboembolism (VTE) following hip fracture surgery (HFS). The purpose of this study is to assess the effectiveness of aspirin to other agents in preventing VTE and mortality following hip fracture surgery., Methods: Following PRISMA guidelines, we performed a search for HFS studies from 1998 to 2023 reporting comparisons between aspirin and other chemoprophylaxis methods for VTE (DVT - deep vein thrombosis; PE - pulmonary embolism). SPSS Meta-analysis function was used to calculate Mean Effect Size Estimate (MESE) and 95 % Confidence Intervals for each outcome. Reverse Fragility Index (RFI) and Fragility Quotient (FQ) were calculated for each study., Results: Of the 847 articles screened, 4 studies with 5 comparisons met the search criteria to be included for analysis. A total of 1194 participants were included in these studies. There was a decreased risk of mortality seen with use of aspirin compared to other agents (MESE = 0.86, 95 % CI: [0.07-1.66]; p=.03). There was no increased risk of DVT or PE with use of aspirin (both p>.4). The overall RFI and FQ for all 19 outcomes were 12 (IQR: 6.5-15) and 0.080 (IQR: 0.027-0.110), respectively. Ten studies (52.6 %) reported a loss-to-follow-up (LTF) greater than the overall RFI., Conclusions: Aspirin demonstrates similar protective effects on prevention of VTE compared to other agents and may have significant protective effects on overall mortality following surgical intervention for hip fractures. However, the current evidence concerning its use in this arena is less than robust, with more than half of the studied outcomes considered statistically fragile., Competing Interests: Frank A Buttacavoli Heraeus: Paid consultant. KCI: Paid consultant. Medtronic: Paid consultant. Sanara MedTech: Paid consultant. Zimmer: Paid consultant. Tyler K Williamson, Victor H Martinez, Adam Aziz, Travis Kotzur, Luke Verlinsky: Nothing to disclose., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Introduction: Despite national efforts to increase diversity and inclusion, underrepresented minority (URM) representation among orthopaedic spine surgery faculty remains low. Research has shown that URM trainees are more likely to pursue surgical careers when they have access to URM mentors. The purpose of this study was to explore the influence of URM representation among spine faculty on the rate of URM orthopaedic residents pursuing spine surgery fellowships., Methods: From 2004 to 2023, data were collected from each residency class at our academic institution: residency year, number of residents per class (total and URM), and number of residents applying to spine surgery fellowships. These ethnicities were considered URM: Black or African American, Hispanic or Latino, and Native American. In 2018, two African American spine faculty were hired. Data were compared between Before and After their arrival. A subanalysis was done to include a period of increasing URM recruitment (2012 to 2018). Binary logistic regression analysis evaluated associations between appointment of URM faculty and fellowship choice of URM residents., Results: Two hundred fifty-six residents were included. Thirty-one total URM residents were in the program during the study period (12.1%). Overall, URM representation in the program increased over time [OR: 1.1, 95% CI: 1.1 to 1.2], whereas residents applying to spine surgery fellowships did not change [OR: 1.0, 95% CI: 1.0 to 1.1]. Comparing Before-2012 and 2012 to 2018 groups with the After-2018 group demonstrated a significant difference in the proportion of URM residents applying to spine surgery fellowships after the hiring of URM spine faculty (0.0% versus 23.1% versus 74.1%; P = 0.001)., Conclusion: This retrospective study provides empirical evidence of the importance of URM representation among orthopaedic spine surgery faculty and the potential effect on URMs pursuing orthopaedic fellowships. Institutions should consider prioritizing the representation of URM faculty in spine surgery to address the lack of current and future diversity in the field., Level of Evidence: III., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Study Design/setting: Retrospective cohort., Objective: Adult spinal deformity (ASD) corrective surgery is often a highly invasive procedure portending patients to both immediate and long-term complications. Therefore, we sought to compare the economic impact of certain complications before and after 2 years., Methods: ASD patients with minimum 3-year data included. Complication groups were defined as follows: any complication, major, medical, mechanical, radiographic, and reoperation. Complications stratified by occurrence before or after 2 years postoperatively. Published methods converted ODI to SF-6D to QALYs. Cost was calculated using CMS.gov definitions. Marginalized means for utility gained and cost-per-QALY were calculated via ANCOVA controlling for significant confounders., Results: 244 patients included. Before 2Y, complication rates: 76% ≥1 complication, 18% major, 26% required reoperation. After 2Y, complication rates: 32% ≥1 complication, 4% major, 2.5% required reoperation. Major complications after 2 years had worse cost-utility (.320 vs .441, P = .1). Patients suffering mechanical complications accrued the highest overall cost ($130,482.22), followed by infection and PJF for complications before 2 years. Patients suffering a mechanical complication after 2 years had lower cost-utility ($109,197.71 vs $130,482.22, P = .041). Patients developing PJF after 2 years accrued a better cost-utility ($77,227.84 vs $96,873.57; P = .038), compared to PJF before 2 years., Conclusion: Mechanical complications had the single greatest impact on cost-utility after adult spinal deformity surgery, but less so after 2 years. Understanding the cost-utility of specific interventions at certain timepoints may mitigate economic burden and prophylactic efforts should strategically be made against early mechanical complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective Cohort Study., Objective: To assess if there is a threshold of baseline disability beyond which the patient-reported outcomes after surgical correction of adult spinal deformity (ASD) are adversely impacted., Background: Patient-reported outcomes vary after correction of adult spinal deformity, even when patients are optimally realigned. There is a paucity of literature examining the impact of baseline disability on patient-reported outcomes in ASD., Methods: Patients with baseline (BL) and two-year data were included. Disability was ranked according to BL Oswestry Disability Index (ODI) into quintiles: Q1 (lowest ODI score) to Q5 (highest ODI score). Adjusted logistic regression analyses evaluated the likelihood of reaching ≥1 MCID in Scoliosis Research Society Outcomes Questionnaire (SRS-22) Pain, SRS-22 Activity, and Short Form-36 physical component summary at two years across disability groups Q1-Q4 with respect to Q5. Sensitivity tests were performed, excluding patients with any "0" Schwab modifiers at BL., Results: Compared with patients in Q5, the odds of reaching MCID in SRS-22 Pain at 2Y were significantly higher for those in Q1 (OR: 3.771), Q2 (OR: 3.006), and Q3 (OR: 2.897), all P <0.021. Similarly, compared with patients in Q5, the odds of reaching MCID in SRS-22 Activity at two years were significantly higher for those in Q2 (OR: 3.454) and Q3 (OR: 2.801), both P <0.02. Lastly, compared with patients in Q5, odds of reaching MCID in Short Form-36 physical component summary at two years were significantly higher for patients in Q1 (OR: 5.350), Q2 (OR: 4.795), and Q3 (OR: 6.229), all P <0.004., Conclusions: This study found that patients presenting with moderate disability at BL (ODI<40) consistently surpassed health-related quality of life outcomes as compared with those presenting with greater levels of disability. We propose that a baseline ODI of 40 represents a disability threshold within which operative inte rvention maximizes patient-reported outcomes. Furthermore, delaying the intervention until patients progress to severe disability may limit the benefits of surgical correction in ASD patients., Level of Evidence: 3., Competing Interests: One or more of the authors (A.S. and P.G.P.) has received funding from Springer (A.S.), Wolters Kluwer Health-Lippincott Williams & Wilkins (A.S.), AAOS (A.S.), Journal of Bone and Joint Surgery (A.S.), North American Spine Society (A.S.), Medicrea (P.G.P.), SpineWave (P.G.P.), Allosource (P.G.P.), Zimmer Biomet (P.G.P.), Globus (P.G.P.), CSRS (P.G.P.), Aesculap (P.G.P.). The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design/setting: Retrospective., Objective: Evaluate the surgical technique that has the greatest influence on the rate of junctional failure following ASD surgery., Summary of Background Data: Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and the use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates., Materials and Methods: ASD patients with two-year(2Y) data and at least 5-level fusion to the pelvis were included. Patients were divided based on UIV: [Longer Construct: T1-T4; Shorter Construct: T8-T12]. Parameters assessed included matching in age-adjusted PI-LL or PT, aligning in GAP-relative pelvic version or Lordosis Distribution Index. After assessing all lumbopelvic radiographic parameters, the combination of realigning the two parameters with the greatest minimizing effect of PJF constituted a good base. Good s was defined as having: (1) prophylaxis at UIV (tethers, hooks, cement), (2) no lordotic change(under-contouring) greater than 10° of the UIV, (3) preoperative UIV inclination angle<30°. Multivariable regression analysis assessed the effects of junction characteristics and radiographic correction individually and collectively on the development of PJK and PJF in differing construct lengths, adjusting for confounders., Results: In all, 261 patients were included. The cohort had lower odds of PJK(OR: 0.5,[0.2-0.9]; P =0.044) and PJF was less likely (OR: 0.1,[0.0-0.7]; P =0.014) in the presence of a good summit. Normalizing pelvic compensation had the greatest radiographic effect on preventing PJF overall (OR: 0.6,[0.3-1.0]; P =0.044). In shorter constructs, realignment had a greater effect on decreasing the odds of PJF(OR: 0.2,[0.02-0.9]; P =0.036). With longer constructs, a good summit lowered the likelihood of PJK(OR: 0.3,[0.1-0.9]; P =0.027). A good base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a good summit lowered the incidence of PJK(OR: 0.4,[0.2-0.9]; P =0.041) and PJF (OR: 0.1,[0.01-0.99]; P =0.049)., Conclusion: To mitigate junctional failure, our study demonstrated the utility of individualizing surgical approaches to emphasize an optimal basal construct. Achievement of tailored goals at the cranial end of the surgical construct may be equally important, especially for higher-risk patients with longer fusions., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Recent debate has arisen between whether to use a three-column osteotomy (3CO) or multilevel low-grade (MLG) techniques to treat severe sagittal malalignment in adult spinal deformity (ASD) surgery. The goal of this study was to compare the outcomes of 3CO and MLG techniques performed in corrective surgeries for ASD., Methods: ASD patients who had a baseline PI-LL > 30° and 2-year follow-up data were included. Patients underwent either 3CO or MLG (thoracolumbar posterior column osteotomies at ≥ 3 levels or anterior lumbar interbody fusion at ≥ 3 levels with no 3CO). The segmental utility ratio was used to assess relative segmental correction (segmental correction divided by overall correction in lordosis divided by the number of thoracolumbar interventions [interbody fusion, thoracolumbar posterior column osteotomies, and 3CO]). The paired t-test was used to assess lordotic distribution by differences in lordosis between adjacent lumbar disc spaces (e.g., L1-2 to L2-3). Multivariate analysis, controlling for age, sex, BMI, osteoporosis, baseline pelvic incidence, and T1 pelvic angle, was used to evaluate the complication rates and radiographic and patient-reported outcomes between the groups., Results: A total of 93 patients were included, 53% of whom underwent MLG and 47% of whom underwent 3CO. The MLG group had a lower BMI (p < 0.05). MLG patients received fewer previous fusions than 3CO patients (31% vs 80%, p < 0.001). MLG patients had 24% less blood loss but a 22% longer operative time (565 vs 419 minutes, p = 0.008). Using adjusted analysis, the 3CO group had greater segmental and relative correction at each level (segmental utility ratio mean 69% for 3CO vs 23% for MLG, p < 0.001). However, the 3CO group had lordotic differences between two adjacent lumbar disc pairs (range -0.5° to 9.0°, p = 0.009), while MLG was more harmonious (range 2.2°-6.5°, p > 0.4). MLG patients were more likely to undergo realignment to age-adjusted standards (OR 5.6, 95% CI 1.2-46.4; p = 0.033). MLG patients were less likely to develop neurological complications or undergo reoperation (OR 0.4, 95% CI 0.1-0.9; p = 0.041). Adjusted analysis revealed that MLG patients more often met a substantial clinical benefit in the Oswestry Disability Index score (OR 5.3, 95% CI 1.1-26.8; p = 0.043)., Conclusions: MLG techniques showed better utility in lumbar distribution and age-adjusted global correction while minimizing neurological complications and reoperation rates by 2 years postoperatively. In selected instances, these techniques may offer the spine deformity surgeon a safer alternative when correcting severe adult spinal deformity.

Study Design: This was a retrospective study., Objective: To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD)., Summary of Background Data: With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny., Materials and Methods: ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes., Results: Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m 2 ), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4°), and pelvic tilt (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P =0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P =0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P =0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria., Conclusions: Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity., Level of Evidence: 3., Competing Interests: P.G.P. has received funding from Medicrea, SpineWave, Allosource, Zimmer Biomet, Globus, CSRS, and Aesculap. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design/setting: This was a retrospective cohort study., Background: Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty., Objective: The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity., Methods: This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely., Results: A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group., Conclusions: Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes., Competing Interests: P.G.P.: Allosource: Other financial or material support; Cervical Scoliosis Research Society: Research support; Globus Medical: Paid presenter or speaker; Medtronic: Paid consultant; Royal Biologics: Paid consultant; Spine: Editorial or governing board; SpineWave: Paid consultant; Terumo: Paid consultant; Zimmer: Paid presenter or speaker. V.L.: DePuy, A Johnson & Johnson Company: Paid presenter or speaker; European Spine Journal : Editorial or governing board; Globus Medical: Paid consultant; International Spine Study Group: Board or committee member; Nuvasive: IP royalties; Scoliosis Research Society: Board or committee member; The Permanente Medical Group: Paid presenter or speaker. R.F.: Nemaris: Stock or stock options. H.J.K.: AAOS: Board or committee member; Alphatec Spine: Paid consultant; AO SPINE: Board or committee member; Cervical Spine Research Society: Board or committee member; HSS Journal , Asian Spine Journal : Editorial or governing board; ISSGF: Research support; K2M: IP royalties; Scoliosis Research Society: Board or committee member; Zimmer: IP royalties. A.H.D.: EOS: Paid consultant; Medicrea: Paid consultant; Medtronic Sofamor Danek: Paid consultant; Novabone: Paid consultant; Orthofix Inc.: Paid consultant; Research support; Southern Spine: IP royalties; Spineart: IP royalties; Paid consultant; Springer: Publishing royalties, financial or material support; Stryker: Paid consultant. J.L.G.: Acuity: IP royalties; Paid consultant; Alan L. & Jacqueline B. Stuart Spine Research: Research support; Cerapedics: Research support; Cingulate Therapeutics: Stock or stock Options; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Global Spine Journal —Reviewer: Editorial or governing board; Intellirod Spine Inc.: Research support; K2M /Stryker: Board or committee member; MAZOR Surgical Technologies: Paid consultant; Medtronic: Board or committee member; Paid consultant; Research support; Norton Healthcare: Research support; Nuvasive: IP royalties; Paid consultant; Pfizer: Research support; Scoliosis Research Society: Research support; Spine Deformity —Reviewer: Editorial or governing board; Stryker: Paid consultant; Paid presenter or speaker; Texas Scottish Rite Hospital: Research support; The Spine Journal —Reviewer: Editorial or governing board. T.S.P.: Altus: IP royalties; Globus Medical: Paid consultant; Medicrea: Paid consultant; Medtronic: Paid consultant; Nuvasive: Paid consultant; Spine Align: Stock or stock Options; Stryker: Paid consultant; Torus Medical: Stock or stock Options. G.M.M.: Carlsmed: Paid consultant; ISSGF: Research support; K2M: IP royalties; Nuvasive: IP royalties; Paid consultant; Research support; Scoliosis Research Society: Board or committee member; SeaSpine: Paid consultant; Stryker: Paid consultant; Viseon: Paid consultant. R.K.E.: Aesculap/B.Braun: Paid consultant; Alphatec Spine: Stock or stock Options; Baxter: Paid consultant; Biedermann-Motech: Paid consultant; Carevature: Paid consultant; Stock or stock Options; Globus Medical: IP royalties; Invuity: Stock or stock Options; Medtronic: Paid consultant; Nocimed: Stock or stock Options; Nuvasive: IP royalties; Paid consultant; Research support; Stock or stock Options; Radius: Paid presenter or speaker; San Diego Spine Foundation: Board or committee member; Scoliosis Research Society: Board or committee member; Seaspine: IP royalties; Paid consultant; Stock or stock Options; SI Bone: IP royalties; Paid consultant; Society of Lateral Access Surgery: Board or committee member; Spine Innovations: Stock or stock Options; Stryker: Paid consultant. K.H.: European Spine Journal : Editorial or governing board; Nuvasive: Research support. E.O.K.: AO Spine: Paid presenter or speaker; Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Medicrea: Paid consultant; Medtronic: Paid consultant; Stryker: Paid consultant. B.G.L.: ISSGF: Paid consultant. R.A.H.: American Orthopaedic Association: Board or committee member; Cervical Spine Research Society: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; Globus Medical: IP royalties; Paid consultant; Paid presenter or speaker; International Spine Study Group: Board or committee member; ISSLS Textbook of the Lumbar Spine: Editorial or governing board; Medtronic: Paid consultant; Paid presenter or speaker; North American Spine Society: Board or committee member; Orthofix Inc.: Paid consultant; Paid presenter or speaker; Scoliosis Research Society: Board or committee member; SeaSpine: IP royalties; Spine Connect: Stock or stock Options; Western Ortho Assn: Board or committee member. D.C.B.: Bioventus: Research support; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Pfizer: Research support; Progenerative Medical: Stock or stock Options; Scoliosis Research Society: Board or committee member; Spine Deformity : Editorial or governing board. P.V.M.: AANS/CNS Spine Section and Scoliosis Research Society: Board or committee member; American Association of Neurological Surgeons: Board or committee member; Cervical Spine Research Society: Board or committee member; Congress of Neurological Surgeons: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Global Spine Journal : Editorial or governing board; Globus Medical: Paid consultant; International Spine Study Group: Research support; Neurosurgery: Editorial or governing board; NREF: Research support; Spinal Deformity: Editorial or governing board; Spinicity/ISD: Stock or stock Options; Springer: Publishing royalties, financial or material support; Stryker: Paid consultant; Taylor and Francis: Publishing royalties, financial or material support; Thieme: Publishing royalties, financial or material support; World Neurosurgery: Editorial or governing board. P.P.: AANS Spine Section: Board or committee member; Cerapedics: Research support; DePuy, A Johnson & Johnson Company: Research support; Globus Medical: IP royalties; Paid consultant; ISSG: Research support; Journal of Neurosurgery Spine : Editorial or governing board; Neurosurgery: Editorial or governing board; North American Spine Society: Board or committee member; Nuvasive: Paid consultant; Operative Neurosurgery: Editorial or governing board; Scoliosis Research Society: Board or committee member; SI-Bone: Research support. F.J.S.: DePuy, A Johnson & Johnson Company: Research support; Globus Medical: Paid consultant; Paid presenter or speaker; K2M: IP royalties; Paid consultant; Paid presenter or speaker; Medicrea: Paid consultant; Medtronic: Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Nuvasive: Research support; Scoliosis Research Society: Board or committee member; Spine Deformity : Editorial or governing board; Stryker: Research support; VP of International Spine Society Group (ISSG): Board or committee member; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker. D.C.: Globus Medical: IP royalties; Paid consultant. C.I.S.: AANS: Board or committee member; Cervical Spine Research Society: Board or committee member; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Research support; Globus Medical: Research support; Medtronic: Other financial or material support; Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Research support; Neurosurgery RRC: Board or committee member; Nuvasive: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Stock or stock Options; Proprio: Paid consultant; Scoliosis Research Society: Board or committee member; SI Bone: IP royalties; Spinal Deformity: Editorial or governing board; Spine: Editorial or governing board. R.S.B.: allosource: Paid consultant; Research support; Biomet: Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Research support; EOS: Research support; Globus Medical: Research support; k2 medical: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Medtronic Sofamor Danek: Research support; North American Spine Society: Board or committee member; Nuvasive: IP royalties; Research support; Orthofix Inc.: Research support; Scoliosis Research Society: Board or committee member; Stryker: IP royalties; Paid presenter or speaker. C.P.A.: Biomet Spine: IP royalties; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Global Spine Analytics—Director: Other financial or material support; International Spine Study Group (ISSG): Research support; International Spine Study Group (ISSG)—Executive Committee: Other financial or material support; K2M: IP royalties; Paid consultant; Medicrea: IP royalties; Paid consultant; Medtronic: Paid consultant; Next Orthosurgical: IP royalties; Nuvasive: IP royalties; Operative Neurosurgery—Editorial Board: Other financial or material support; Scoliosis Research Society (SRS)—Grant Funding: Other financial or material support; Stryker: IP royalties; Titan Spine: Research support. J.S.S.: Alphatec Spine: Stock or stock Options; Carlsmed: Paid consultant; Cerapedics: Paid consultant; DePuy: Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Journal of Neurosurgery Spine : Editorial or governing board; Neurosurgery: Editorial or governing board; Nuvasive: IP royalties; Paid consultant; Research support; Operative Neurosurgery: Editorial or governing board; Scoliosis Research Society: Board or committee member; Spine Deformity : Editorial or governing board; Stryker: Paid consultant; Thieme: Publishing royalties, financial or material support; Zimmer: IP royalties; paid consultant. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms., Methods: We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes., Results: Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE., Conclusion: Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Study Design: Retrospective study., Objective: Evaluate surgical characteristics and postoperative 2-year results of the PL approach to spinal fusion., Summary of Background Data: Prone-lateral(PL) single positioning has recently gained popularity in spine surgery due to lower blood loss and operative time but has yet to be examined for other notable outcomes, including realignment and patient-reported measures., Materials and Methods: We included circumferential spine fusion patients with a minimum one-year follow-up. Patients were stratified into groups based on undergoing PL approach versus same-day staged (Staged). Mean comparison tests identified differences in baseline parameters. Multivariable logistic regression, controlling for age, levels fused, and Charlson Comorbidity Index were used to determine the influence of the approach on complication rates, radiographic and patient-reported outcomes up to two years., Results: One hundred twenty-two patients were included of which 72(59%) were same-day staged and 50(41%) were PL. PL patients were older with lower body mass index (both P <0.05). Patients undergoing PL procedures had lower estimated blood loss and operative time (both P <0.001), along with fewer osteotomies (63% vs. 91%, P <0.001). This translated to a shorter length of stay (3.8 d vs. 4.9, P =0.041). PL procedures demonstrated better correction in both PT (4.0 vs. -0.2, P =0.033 and pelvic incidence and lumbar lordosis (-3.7 vs. 3.1, P =0.012). PL procedures were more likely to improve in GAP relative pelvic version (OR: 2.3, [1.5-8.8]; P =0.003]. PL patients suffered lesser complications during the perioperative period and greater improvement in NRS-Back (-6.0 vs. -3.3, P =0.031), with less reoperations (0.0% vs. 4.8%, P =0.040) by two years., Conclusions: Patients undergoing PL single-position procedures received less invasive procedures with better correction of pelvic compensation, as well as earlier discharge. The prone lateral cohort also demonstrated greater clinical improvement and a lower rate of reoperations by two years following spinal corrective surgery., Level of Evidence: Level-III., Competing Interests: P.G. P. provides research support for Cervical Scoliosis Research Society; is a paid presenter or speaker for Globus Medical; paid consultant for Medtronic, Royal Biologics, SpineWave, and Terumo; is on the Editorial or governing board for Spine; and received other financial or material support from Cerapedics and Spinevision. P.P. is a Committee member of AANS Spine Section; provides research support for Cerapedics, ISSG, DePuy, SI-Bone, and A Johnson & Johnson Company; is a committee member of AANS Spine Section, North American Spine Society, and Scoliosis Research Society; is on the editorial or governing board of Journal of Neurosurgery: Spine , Neurosurgery, and Operative Neurosurgery; and is a paid consultant for Globus Medical: IP royalties and Nuvasive. D.C. is a paid consultant for Globus Medical: IP royalties and Orthofix, Inc. A.S. is a board or committee member of AAOS and North American Spine Society; is on the editorial or governing board of Journal of Bone and Joint Surgery—American and Spine; received publishing royalties and financial or material support from Wolters Kluwer Health—Lippincott Williams & Wilkins and Springer. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design/setting: Retrospective single-center study., Background: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD)., Purpose: Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD., Methods: Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years., Results: One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF., Conclusion: The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement., Competing Interests: P.G.P.: Allosource: other financial or material support; Cervical Scoliosis Research Society: research support; Globus Medical: paid presenter or speaker; Medicrea: paid consultant; Royal Biologics: paid consultant; SpineWave: paid consultant; Terumo: paid consultant; Zimmer: paid presenter or speaker. R.L.: Nemaris: stock or stock options. V.L.: DePuy, A Johnson & Johnson Company: paid presenter or speaker; European Spine Journal : editorial or governing board; Globus Medical: paid consultant; International Spine Study Group: board or committee member; Nuvasive: IP royalties; Scoliosis Research Society: Board or committee member; The Permanente Medical Group: paid presenter or speaker. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks., Purpose: The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients., Study Design/setting: This was a retrospective cohort study of the PearlDiver database., Patient Sample: We enrolled 670,526 patients undergoing spine fusion surgery., Outcome Measures: Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs., Methods: Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05., Results: Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013)., Conclusions: When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Craniovertebral Junction and Spine.)

Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: The Roussouly, SRS-Schwab, and Global Alignment and Proportion (GAP) classifications define alignment by spinal shape and deformity severity. The efficacy of different surgical approaches and techniques to successfully achieve these goals is not well understood., Purpose: Identify the impact of surgical approach and/or technique on meeting complex realignment goals in adult spinal deformity (ASD) corrective surgery., Study Design/setting: Retrospective study., Materials and Methods: Included patients with ASD fused to pelvis with 2-year data. Patients were categorized by: (1) Roussouly: matching current and theoretical spinal shapes, (2) improving in SRS-Schwab modifiers (0, +, ++), and (3) improving GAP proportionality by 2 years. Analysis of covariance and multivariable logistic regression analyses controlling for age, levels fused, baseline deformity, and 3-column osteotomy usage compared the effect of different surgical approaches, interbody, and osteotomy use on meeting realignment goals., Results: A total of 693 patients with ASD were included. By surgical approach, 65.7% were posterior-only and 34.3% underwent anterior-posterior approach with 76% receiving an osteotomy (21.8% 3-column osteotomy). By 2 years, 34% matched Roussouly, 58% improved in GAP, 45% in SRS-Schwab pelvic tilt (PT), 62% sagittal vertical axis, and 70% pelvic incidence-lumbar lordosis. Combined approaches were most effective for improvement in PT [odds ratio (OR): 1.7 (1.1-2.5)] and GAP [OR: 2.2 (1.5-3.2)]. Specifically, anterior lumbar interbody fusion (ALIF) below L3 demonstrated higher rates of improvement versus TLIFs in Roussouly [OR: 1.7 (1.1-2.5)] and GAP [OR: 1.9 (1.3-2.7)]. Patients undergoing pedicle subtraction osteotomy at L3 or L4 were more likely to improve in PT [OR: 2.0 (1.0-5.2)] and pelvic incidence-lumbar lordosis [OR: 3.8 (1.4-9.8)]. Clinically, patients undergoing the combined approach demonstrated higher rates of meeting SCB in Oswestry Disability Index by 2 years while minimizing rates of proximal junctional failure, most often with an ALIF at L5-S1 [Oswestry Disability Index-SCB: OR: 1.4 (1.1-2.0); proximal junctional failure: OR: 0.4 (0.2-0.8)]., Conclusions: Among patients undergoing ASD realignment, optimal lumbar shape and proportion can be achieved more often with a combined approach. Although TLIFs, incorporating a 3-column osteotomy, at L3 and L4 can restore lordosis and normalize pelvic compensation, ALIFs at L5-S1 were most likely to achieve complex realignment goals with an added clinical benefit and mitigation of junctional failure., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postoperative reciprocal changes (RC) in the cervical spine associated with varying factors of proximal junctional kyphosis (PJK) following fusions of the thoracopelvic spine are poorly understood., Purpose: Explore reciprocal changes in the cervical spine associated with varying factors (severity, progression, patient age) of PJK in patients undergoing adult spinal deformity (ASD) correction., Patients and Methods: Retrospective review of a multicenter ASD database., Inclusion: ASD patients > 18 y/o, undergoing fusions from the thoracic spine (UIV: T6-T12) to the pelvis with two-year radiographic data. ASD was defined as: Coronal Cobb angle ≥ 20°, Sagittal Vertical Axis ≥ 5 cm, Pelvic Tilt ≥ 25°, and/or Thoracic Kyphosis ≥ 60°. PJK was defined as a ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Patients were grouped by mild (M; 10°-20°) and severe (S; > 20°) PJK at one year. Propensity Score Matching (PSM) controlled for CCI, age, PI and UIV. Unpaired and paired t test analyses determined difference between RC parameters and change between time points. Pearson bi-variate correlations analyzed associations between RC parameters (T4-T12, TS-CL, cSVA, C2-Slope, and T1-Slope) and PJK descriptors., Results: 284 ASD patients (UIV: T6: 1.1%; T7: 0.7%; T8: 4.6%; T9: 9.9%; T10: 58.8%; T11: 19.4%; T12: 5.6%) were studied. PJK analysis consisted of 182 patients (Mild = 91 and Severe = 91). Significant difference between M and S groups were observed in T4-T12 Δ1Y(- 16.8 v - 22.8, P = 0.001), TS-CLΔ1Y(- 0.6 v 2.8, P = 0.037), cSVAΔ1Y(- 1.8 v 1.9, P = 0.032), and C2 slopeΔ1Y(- 1.6 v 2.3, P = 0.022). By two years post-op, all changes in cervical alignment parameters were similar between mild and severe groups. Correlation between age and cSVAΔ1Y(R = 0.153, P = 0.034) was found. Incidence of severe PJK was found to correlate with TS-CLΔ1Y(R = 0.142, P = 0.049), cSVAΔ1Y(R = 0.171, P = 0.018), C2SΔ1Y(R = 0.148, P = 0.040), and T1SΔ2Y(R = 0.256, P = 0.003)., Conclusions: Compensation within the cervical spine differed between individuals with mild and severe PJK at one year postoperatively. However, similar levels of pathologic change in cervical alignment parameters were seen by two years, highlighting the progression of cervical compensation due to mild PJK over time. These findings provide greater evidence for the development of cervical deformity in individuals presenting with proximal junctional kyphosis., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design/setting: Retrospective cohort study., Objective: Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery., Methods: ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility., Results: By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R 2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R 2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r 2 = .408, P < .001)., Conclusions: The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions. Level of evidence: III., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Peter Gust Passias, MDAllosource: Other financial or material support Cervical Scoliosis Research Society: Research support Globus Medical: Paid presenter or speaker Medtronic: Paid consultant Royal Biologics: Paid consultant Spine: Editorial or governing board SpineWave: Paid consultant Terumo: Paid consultant Zimmer: Paid presenter or speaker. Virginie Lafage, PhD DePuy, A Johnson & Johnson Company: Paid presenter or speaker European Spine Journal: Editorial or governing board Globus Medical: Paid consultant International Spine Study Group: Board or committee member Nuvasive: IP royalties Scoliosis Research Society: Board or committee member The Permanente Medical Group: Paid presenter or speaker. Ferran Pellise, MDAOSpine Deformity Knowledge Forum: Board or committee member DePuy, A Johnson & Johnson Company: Research support European Spine Journal: Editorial or governing board EuroSpine, The Spine Society of Europe: Board or committee member Medtronic: Paid consultant; Research support Scoliosis Research Society: Board or committee member Spanish Spine Society, GEER: Board or committee member Stryker: Paid consultant. Renaud Lafage, MS Nemaris: Stock or stock Options. Munish C Gupta, MD. AO Spine Faculty, travel: Board or committee memberDePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker European Spine Journal-Advisory Board: Editorial or governing board Global Spine Journal-Reviewer: Editorial or governing board Globus Medical: IP royalties; Paid consultant honorarium for faculty: Board or committee member Innomed: IP royalties Johnson & Johnson: Stock or stock Options Medtronic: Paid consultant Spine Deformity, Reviewer: Editorial or governing board SRS-Board of Directors: Board or committee member SRS-IMAST & Education committee: Board or committee member travel: Board or committee member Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support. Michael Patrick Kelly, MD, MSc, AO Spine: Board or committee memberCervical Spine Research Society: Board or committee member Scoliosis Research Society: Board or committee member Spine: Editorial or governing board. Han Jo Kim, MDAAOS: Board or committee member Alphatec Spine: Paid consultant AO SPINE: Board or committee member Cervical Spine Research Society: Board or committee member HSS Journal, Asian Spine Journal: Editorial or governing board ISSGF: Research support K2M: IP royalties Scoliosis Research Society: Board or committee member Zimmer: IP royalties. Khaled M Kebaish, MDDePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; Research support Orthofix, Inc.: IP royalties; Paid consultant Orthofix, Inc., K2 medical Inc: Paid presenter or speaker Scoliosis Research Society: Board or committee member Stryker: IP royalties. Alan H Daniels, MDEOS: Paid consultant Medicrea: Paid consultant Medtronic Sofamor Danek: Paid consultant Novabone: Paid consultant Orthofix, Inc.: Paid consultant; Research support Southern Spine: IP royalties Spineart: IP royalties; Paid consultant Springer: Publishing royalties, financial or material support Stryker: Paid consultant. Andrew J Schoenfeld, MDAAOS: Board or committee member Journal of Bone and Joint Surgery - American: Editorial or governing board North American Spine Society: Board or committee member Spine: Editorial or governing board Springer: Publishing royalties, financial or material support Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support. Jeffrey Gum, MDAcuity: IP royalties; Paid consultant Alan L. & Jacqueline B. 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Themistocles Stavros Protopsaltis, MDAltus: IP royalties Globus Medical: Paid consultant Medicrea: Paid consultant Medtronic: Paid consultant Nuvasive: Paid consultant Spine Align: Stock or stock Options Stryker: Paid consultant Torus Medical: Stock or stock Options. Ibrahim ObeidAlphatec Spine: IP royalties; Paid consultant Clariance: IP royalties DePuy, A Johnson & Johnson Company: Paid consultant; Paid presenter or speaker; Research support Medtronic Sofamor Danek: Paid consultant; Paid presenter or speaker SPINEART: IP royalties. Gregory Michael Mundis Jr, MDCarlsmed: Paid consultant ISSGF: Research support K2M: IP royalties Nuvasive: IP royalties; Paid consultant; Research support Scoliosis Research Society: Board or committee member SeaSpine: Paid consultant Stryker: Paid consultant Viseon: Paid consultant. Dean Chou, MDGlobus Medical: IP royalties; Paid consultant Orthofix, Inc.: Paid consultant. 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Robert A Hart, MD, FAAOSAmerican Orthopaedic Association: Board or committee member Cervical Spine Research Society: Board or committee member DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker Globus Medical: IP royalties; Paid consultant; Paid presenter or speaker International Spine Study Group: Board or committee member ISSLS Textbook of the Lumbar Spine: Editorial or governing board Medtronic: Paid consultant; Paid presenter or speaker North American Spine Society: Board or committee member Orthofix, Inc.: Paid consultant; Paid presenter or speaker Scoliosis Research Society: Board or committee member SeaSpine: IP royalties Spine Connect: Stock or stock Options Western Ortho Assn: Board or committee member. 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Justin S Smith, MDAlphatec Spine: Stock or stock Options Carlsmed: Paid consultant Cerapedics: Paid consultant DePuy: Research support DePuy, A Johnson & Johnson Company: Paid consultant Journal of Neurosurgery Spine: Editorial or governing board Neurosurgery: Editorial or governing board Nuvasive: IP royalties; Paid consultant; Research support Operative Neurosurgery: Editorial or governing board Scoliosis Research Society: Board or committee member Spine Deformity: Editorial or governing board Stryker: Paid consultant Thieme: Publishing royalties, financial or material support Zimmer: IP royalties; Paid consultant.

Background: Multiple forms of electrical stimulation (ES) potentially offer widely varying clinical benefits. Diminished function commonly associated with acute and chronic pain lessens productivity and increases medical costs. This review aims to compare the relative effects of various forms of ES on functional and pain outcomes., Methods: A comprehensive literature search focused on studies of commonly marketed forms of ES used for treatment of pain and improvement of function. Peer-reviewed manuscripts were categorized as "Important" (systematic review or meta-analysis, randomized controlled trial, observational cohort study) and "Minor" (retrospective case series, case report, opinion review) for each identified form of ES., Results and Discussion: Varying forms of ES have markedly different technical parameters, applications, and indications, based on clinically meaningful impact on pain perception, function improvement, and medication reduction. Despite being around for decades, there is limited quality evidence for most forms of ES, although there are several notable exceptions for treatment of specific indications. Neuromuscular electrical stimulation (NMES) has well-demonstrated beneficial effects for rehabilitation of selective spinal cord injured (SCI), post-stroke, and debilitated inpatients. Functional electrical stimulation (FES) has similarly shown effectiveness in rehabilitation of some stroke, SCI, and foot drop outpatients. H-Wave ® device stimulation (HWDS) has moderate supportive evidence for treatment of acute and refractory chronic pain, consistently demonstrating improvements in function and pain measures across diverse populations. Interestingly, transcutaneous electrical nerve stimulation (TENS), the most widely used form of ES, demonstrated insignificant or very low levels of pain and functional improvement., Conclusion: Ten of 13 reviewed forms of ES have only limited quality evidence for clinically significant reduction of pain or improvement of function across different patient populations. NMES and FES have reasonably demonstrated effectiveness, albeit for specific clinical rehabilitation indications. HWDS was associated with the most clinically significant outcomes, in terms of functional improvement combined with reduction of pain and medication use. More rigorous long-term clinical trials are needed to further validate appropriate use and specific indications for most forms of ES., Level of Evidence: II., (© 2023. The Author(s).)

Study Design: Retrospective cohort study., Objective: Understand the benefit of addressing malalignment in revision surgery for proximal junctional kyphosis (PJK)., Summary of Background Data: PJK is a common cause of revision surgery for adult spinal deformity patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbopelvic mismatch., Materials and Methods: Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor (proximal extension of fusion alone compared with combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbopelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria [Global Alignment and Proportionality (GAP), Roussouly-type, and Sagittal Age-Adjusted Score (SAAS)]., Results: A total of 151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP postrevision had lower rates of recurrent PJK [23% vs. 42%; odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8, P =0.024]. Following adjusted analysis, patients who were ideally aligned in one of three criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%; OR: 0.4, 95% CI: 0.1-0.9, P =0.035) and recurrent PJF (OR: 0.1, 95% CI: 0.02-0.7, P =0.015). Patients ideally aligned in two of three criteria avoid any development of PJF (0% vs. 16%, P <0.001)., Conclusions: Following revision surgery for PJK, patients with persistent poor sagittal alignment showed increased rates of recurrent PJK compared with patients who had abnormal lumbopelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs)., Methods: This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected., Results: These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions., Conclusion: Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis., (© 2023 The Authors.)

Context: Upon requests from osteopathic medical schools, the National Resident Matching Program (NRMP) Charting Outcomes were redesigned to include osteopathic medical school seniors beginning in 2018 and one joint graduate medical education (GME) accreditation system, the Accreditation Council for Graduate Medical Education (ACGME), formed in 2020., Objectives: The goal of this study is to analyze the match outcomes and characteristics of osteopathic applicants applying to surgical specialties following the ACGME transition., Methods: A retrospective analysis of osteopathic senior match outcomes in surgical specialties from the NRMP Main Residency Match data from 2020 to 2022 and the NRMP Charting Outcomes data from 2020 to 2022 was performed., Results: For surgical specialties, results show matching increased as United States Medical Licensing Examination (USMLE) Step 2 CK (clinical knowledge) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 CE (cognitive evaluation) scores increased along with the number of contiguous rankings (p<0.001). The greatest indication for matching looking at scores alone were those who scored greater than 230 on Step 2 CK compared to below (p<0.001) and above 650 on Level 2 CE (p<0.001). However, those who scored 240 (p=0.025) on Step 2 CK were just as likely to match as those who scored 250 (p=0.022) when compared to those who scored below those scores. Increasing research involvement had little to no significance with the likelihood of matching across most surgical subspecialties., Conclusions: Our study demonstrates that there are unique thresholds for Step 2 CK scores, Level 2 CE scores, and the number of contiguous ranks for each surgical specialty that, when reached, are significantly associated with match success. Although certain board score delineations are linked with higher match success rates, the rates level off after this point for most surgical specialties and do not significantly increase further with higher scores. In addition, thresholds within contiguous ranks for increasing match likelihood exist and vary across surgical specialties. Overall, this study highlights that the quantitative metrics utilized to assess applicants lack the correlation reported historically, and the data presently available need to be more substantiated., (© 2023 the author(s), published by De Gruyter, Berlin/Boston.)

Introduction: Orthopaedic surgery is one of the least diverse fields in medicine. In recent decades, there has been a concerted effort to increase diversity, equity, and inclusion (DEI) in the specialty, in addition to the institution of several organizations to establish the pipeline and facilitate underrepresented minority students into orthopaedic surgery. The aim of this study was to examine trends in orthopaedic surgery DEI research., Methods: A search of DEI articles was conducted in orthopaedic surgery using PubMed, MEDLINE, EMBASE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center. The year of publication, article topic of focus, sex of the primary author, publishing journal, citation index, and primary contributing institution were recorded for each article. Sex of the primary author was predicted by the authors using an online image search of the author and institution. Articles were excluded if the research was conducted outside of the United States or if they were not specific to orthopaedic surgery., Results: A total of 143 articles met the inclusion criteria. A total of 52.4% of authors (n = 75) were women and 44.1% (n = 63) were men. A total of 42.7% of the articles were written about sex (n = 61), 39.9% about race/ethnicity and sex (n = 57), and 11.9% about race/ethnicity (n = 17). A total of 10 articles were affiliated with Washington University in St. Louis while 51 other institutions wrote the remaining articles, with none having more than 4. Information could not be confirmed for 5 articles. In 2018, 5 articles were published, followed by 17 in 2019, 25 in 2020, 34 in 2021, and 30 in 2022., Conclusion: DEI research in orthopaedic surgery is a relatively new venture within the specialty and has room to grow, specifically in the examination of race/ethnicity and inclusion strategies. Leading journals and academic institutions in orthopaedic surgery should incentivize productivity and authorship in DEI research., Level of Evidence: III., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A575)., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning., Materials and Methods: This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded., Results: One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026)., Conclusions: Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Craniovertebral Junction and Spine.)

Background: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications., Objective: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers., Study Design/setting: Retrospective cohort study of a prospectively collected multicenter database., Methods: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility., Results: A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years., Conclusions: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.

Objective: The objective of this study was to adjust the sagittal age-adjusted score (SAAS) to accommodate frailty in alignment considerations and thereby increase the predictability of clinical outcomes and junctional failure., Methods: Surgical adult spinal deformity (ASD) patients with 2-year data were included. Frailty was assessed with the continuous ASD modified frailty index (ASD-mFI). Two-year outcomes were proximal junctional kyphosis (PJK), proximal junctional failure (PJF), major mechanical complications, and best clinical outcome (BCO), defined as Oswestry Disability Index (ODI) score < 15 and Scoliosis Research Society outcomes questionnaire total score > 4.5 by 2 years. Linear regression analysis established a 6-week score based on the component scores of SAAS, frailty, and US normal values for ODI score. Logistic regression analysis followed by conditional inference tree run forest analysis generated categorical thresholds. Multivariate analysis, controlling for age, baseline deformity, and history of revision, was used to compare outcome rates, and logistic regression generated odds ratios for the continuous score. Thirty percent of the cohort was used as a random sample for internal validation., Results: In total, 412 patients were included (mean ± SD age 60.1 ± 14.2 years, 80% female, BMI 26.9 ± 5.4 kg/m2). Baseline frailty categories were as follows: 57% not frail, 30% frail, and 14% severely frail. Overall, by 2 years, 39% of patients had developed PJK, 8% PJF, and 21% mechanical complications; 22% had undergone a reoperation; and 15% met BCO. When the cohort as a whole was assessed, the 6-week SAAS had a correlation with the development of PJK and PJF, but not mechanical complications, reoperation, or BCO. Development of mechanical complications, PJF, reoperation, and BCO demonstrated correlations with ASD-mFI (all p < 0.05). Regression analysis modifying SAAS on the basis of ODI norms and frailty generated the following equation: frailty-adjusted SAAS (FAS) = 0.108 × T1 pelvic angle + 0.162 × pelvic tilt - 0.39 × pelvic incidence - lumbar lordosis - 0.03 × ASD-mFI - 1.6771. With conditional inference tree analysis, thresholds were derived for FAS: aligned < 1.7, offset 1.7-2.2, and severely offset > 2.2. Significance between FAS categories was found for PJK, PJF, mechanical complications, reoperation, and BCO by 2 years. Binary logistic regression, controlling for baseline deformity and revision status, demonstrated significance between FAS and all 5 outcome variables (all p < 0.01). Internal validation saw each outcome variable maintain significance between categories, with even greater odds for PJF (OR 13.4, 95% CI 4.7-38.3, p < 0.001)., Conclusions: Consideration of physiological age, in addition to chronological age, may be beneficial in the management of operative goals to maximize clinical outcomes while minimizing junctional failure. This combination enables the spine surgeon to fortify a surgical plan for even the most challenging patients undergoing ASD corrective surgery.

Study Design: Retrospective cohort study., Objective: Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes., Summary of Background Data: The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications., Materials and Methods: We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score., Results: Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation., Conclusion: This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity., Level of Evidence: III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: As our focus on delivering cost effective healthcare increases, interventions like cervical deformity surgery, which are associated with high resource utilization, have received greater scrutiny. The purpose of this study was to assess relationship between surgical costs, deformity correction, and patient reported outcomes in ACD surgery., Methods: ACD Patients ≥ 18 years with baseline (BL) and 2-year (2Y) data were included. Cost of surgery was calculated by applying average Medicare reimbursement rates by CPT code to surgical details of each patient in the cohort. CPT codes for corpectomy, ACDF, osteotomy, decompression, levels fused, and instrumentation were considered in the analysis. Costs of complications and reoperations were intentionally excluded from the cost analysis. Patients were ranked into two groups by surgical cost: lowest cost (LC) and highest cost (HC). ANCOVA assessed differences in outcomes while accounting for covariates as appropriate., Results: 113 met inclusion criteria. While mean age, frailty, BMI and gender composition were similar between cost groups, mean CCI was significantly higher in the HC group compared to that of the LC group (p=.014). At baseline, LC and HC groups had similar HRQLs and radiographic deformity (all p >.05). Logistic regression accounting for baseline age, deformity and CCI found that HC patients had significantly lower odds of undergoing reoperation within 2-years (OR: 0.309, 95 % CI: 0.193 - 0.493, p <.001). Furthermore, logistic regression accounting for baseline age, deformity and CCI found odds of DJF were significantly lower for those in the HC group (OR: 0.163, 95 % CI: 0.083 - 0.323, p <.001). At 2-years, logistic regression accounting for age and baseline TS-CL found HC patients still had significantly higher odds of reaching a "0″ TS-CL modifier at 2-years (OR: 3.353, 95 % CI: 1.081 - 10.402, p=.036). Logistic regression accounting for age and baseline NDI score found HC patients had significantly higher odds of reaching MCID in NDI at 2-years (OR: 4.477, 95 % CI: 1.507 - 13.297, p=.007). A similar logistic regression accounting for age and baseline mJOA score found odds of reaching MCID in mJOA significantly higher for high-cost patients (OR: 2.942, 95 % CI: 1.101 - 7.864, p=.031)., Conclusions: While patient presentation influences surgical planning and costs, this study attempted to control for such variations to assess impact of surgical costs on outcomes. Despite continued scrutiny over healthcare costs, we found that more costly surgical interventions can produce superior radiographic alignment as well as patient reported outcomes for patients with cervical deformity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: To explore the changes in health-related quality of life parameters observed in patients experiencing varying degrees of proximal junctional kyphosis following corrective adult spinal deformity fusions., Methods: Inclusion: adult spinal deformity patients > 18 y/o, undergoing spinal fusion. PJK: ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Severe PJK: > 28° PJK. Mild PJK: ≥ 10 o and ≤ 28°. ANOVA, followed by ANCOVA, compared the change in HRQoLs between time points (BL, 1Y, 2Y) among PJK groups. Correlation-related change in PJK and change in HRQoL for mild and severe groups., Results: 969 patients (age: 64.5 y/o,75% F, posterior levels fused:12.3) were studied. 59% no PJK, 32% mild PJK, 9% severe PJK. No differences in HRQoLs were seen between no PJK and PJK groups at baseline, one year, and 2 years. Adjusted analysis revealed Severe PJK patients improved less in SRS-22 Satisfaction (NoPJK: 1.6, MildPJK: 1.6, SeverePJK: 1.0; p = 0.022) scores at 2 years. Linear regression analysis only found clinical improvement in SRS-22 Satisfaction to correlate with the change of the PJK angle by 2 years (R = 0.176, P = 0.008). No other HRQoL metric correlated with either the incidence of PJK or the change in the PJK angle by one or 2 years., Conclusions: These results maintain that patients presenting with and without proximal junctional kyphosis report similar health-related qualities of life following corrective adult spinal deformity surgery, and SRS-22 Satisfaction may be a clinical correlate to the degree of PJK. Rather than proving proximal junctional kyphosis to have a minimal clinical impact overall on HRQoL metrics, these data suggest that future analysis of this phenomenon requires different assessments., Level of Evidence: Level of evidence: III., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Despite adequate correction, the pelvis may fail to readjust, deemed pelvic nonresponse (PNR). To assess alignment outcomes [PNR, proximal junctional kyphosis (PJK), postoperative cervical deformity (CD)] following adult spinal deformity (ASD) surgery utilizing different realignment strategies., Materials and Methods: ASD patients with two-year data were included. PNR defined as undercorrected in age-adjusted pelvic tilt (PT) at six weeks and maintained at two years. Patients classified by alignment utilities: (a) improvement in Scoliosis Research Society-Schwab sagittal vertical axis, (b) matching in age-adjusted pelvic incidence-lumbar lordosis, (c) matching in Roussouly, (d) aligning Global Alignment and Proportionality (GAP) score. Multivariable regression analyses, controlling for age, baseline deformity, and surgical factors, assessed rates of PNR, PJK, and CD development following realignment., Results: A total of 686 patients met the inclusion criteria. Rates of postoperative PJK and CD were not significant in the PNR group (both P >0.15). PNR patients less often met substantial clinical benefit in Oswestry Disability Index by two years [odds ratio: 0.6 (0.4-0.98)]. Patients overcorrected in age-adjusted pelvic incidence-lumbar lordosis, matching Roussouly, or proportioned in GAP at six weeks had lower rates of PNR (all P <0.001). Incremental addition of classifications led to 0% occurrence of PNR, PJK, and CD. Stratifying by baseline PT severity, Low and moderate deformity demonstrated the least incidence of PNR (7.7%) when proportioning in GAP at six weeks, while severe PT benefited most from matching in Roussouly (all P <0.05)., Conclusions: Following ASD corrective surgery, 24.9% of patients showed residual pelvic malalignment. This occurrence was often accompanied by undercorrection of lumbopelvic mismatch and less improvement of pain. However, overcorrection in any strategy incurred higher rates of PJK. We recommend surgeons identify a middle ground using one, or more, of the available classifications to inform correction goals in this regard., Level of Evidence: III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recent studies have suggested achieving global alignment and proportionality (GAP) alignment may influence mechanical complications after adult spinal deformity (ASD) surgery., Objective: To investigate the association between the GAP score and mechanical complications after ASD surgery., Methods: Patients with ASD with at least 5-level fusion to pelvis and minimum 2-year data were included. Multivariate analysis was used to find an association between proportioned (P), GAP-moderately disproportioned, and severely disproportioned (GAP-SD) states and mechanical complications (inclusive of proximal junctional kyphosis [PJK], proximal junctional failure [PJF], and implant-related complications [IC]). Severe sagittal deformity was defined by a "++" in the Scoliosis Research Society (SRS)-Schwab criteria for sagittal vertebral axis or pelvic incidence and lumbar lordosis., Results: Two hundred ninety patients with ASD were included. Controlling for age, Charlson comorbidity index, invasiveness and baseline deformity, and multivariate analysis showed no association of GAP-moderately disproportioned patients with proximal junctional kyphosis, PJF, or IC, while GAP-SD patients showed association with IC (odds ratio [OR]: 1.7, [1.1-3.3]; P = .043). Aligning in GAP-relative pelvic version led to lower likelihood of all 3 mechanical complications (all P < .04). In patients with severe sagittal deformity, GAP-SD was predictive of IC (OR: 2.1, [1.1-4.7]; P = .047), and in patients 70 years and older, GAP-SD was also predictive of PJF development (OR: 2.5, [1.1-14.9]; P = .045), while improving in GAP led to lower likelihood of PJF (OR: 0.2, [0.02-0.8]; P = .023)., Conclusion: Severely disproportioned in GAP is associated with development of any IC and junctional failure specifically in older patients and those with severe baseline deformity. Therefore, incorporation of patient-specific factors into realignment goals may better strengthen the utility of this novel tool., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: Management of adult spinal deformity (ASD) has increasingly favored operative intervention; however, the incidence of complications and reoperations is high, and patients may fail to achieve idealized postsurgical results. This study compared health-related quality of life (HRQOL) metrics between patients with suboptimal surgical outcomes and those who underwent nonoperative management as a proxy for the natural history (NH) of ASD., Methods: ASD patients with 2-year data were included. Patients who were offered surgery but declined were considered nonoperative (i.e., NH) patients. Operative patients with suboptimal outcome (SOp)-defined as any reoperation, major complication, or ≥ 2 severe Scoliosis Research Society (SRS)-Schwab modifiers at follow-up-were selected for comparison. Propensity score matching (PSM) on the basis of baseline age, deformity, SRS-22 Total, and Charlson Comorbidity Index score was used to match the groups. ANCOVA and stepwise logistic regression analysis were used to assess outcomes between groups at 2 years., Results: In total, 441 patients were included (267 SOp and 174 NH patients). After PSM, 142 patients remained (71 SOp 71 and 71 NH patients). At baseline, the SOp and NH groups had similar demographic characteristics, HRQOL, and deformity (all p > 0.05). At 2 years, ANCOVA determined that NH patients had worse deformity as measured with sagittal vertical axis (36.7 mm vs 21.3 mm, p = 0.025), mismatch between pelvic incidence and lumbar lordosis (11.9° vs 2.9°, p < 0.001), and pelvic tilt (PT) (23.1° vs 20.7°, p = 0.019). The adjusted regression analysis found that SOp patients had higher odds of reaching the minimal clinically important differences in Oswestry Disability Index score (OR [95% CI] 4.5 [1.7-11.5], p = 0.002), SRS-22 Activity (OR [95% CI] 3.2 [1.5-6.8], p = 0.002), SRS-22 Pain (OR [95% CI] 2.8 [1.4-5.9], p = 0.005), and SRS-22 Total (OR [95% CI] 11.0 [3.5-34.4], p < 0.001)., Conclusions: Operative patients with SOp still experience greater improvements in deformity and HRQOL relative to the progressive radiographic and functional deterioration associated with the NH of ASD. The NH of nonoperative management should be accounted for when weighing the risks and benefits of operative intervention for ASD.

Study Design: Retrospective cohort study., Objective: Construct an individualized cervical realignment strategy based on patient parameters at the presentation that results in superior 2-year health-related quality of life metrics and decreased rates of junctional failure and reoperation following adult cervical deformity surgery., Summary of Background Data: Research has previously focused on adult cervical deformity realignment thresholds for maximizing clinical outcomes while minimizing complications. However, realignment strategies may differ based on patient presentation and clinical characteristics., Methods: We included adult cervical deformity patients with 2-year data. The optimal outcome was defined as meeting good clinical outcomes without distal junctional failure or reoperation. Radiographic parameters assessed included C2 Slope, C2-C7, McGregor's slope, TS-CL, cSVA, T1 slope, and preoperative lowest-instrumented vertebra (LIV) inclination angle. Conditional inference trees were used to establish thresholds for each parameter based on achieving the optimal outcome. Analysis of Covariance and multivariable logistic regression analysis, controlling for age, comorbidities, baseline deformity and disability, and surgical factors, assessed outcome rates for the hierarchical approach within each deformity group., Results: One hundred twenty-seven patients were included. After correction, there was a significant difference in meeting the optimal outcome when correcting the C2 slope below 10 degrees (85% vs. 34%, P <0.001), along with lower rates of distal junctional failure (DJF) (7% vs. 42%, P <0.001). Next, after isolating patients below the C2 slope threshold, the selection of LIV with an inclination between 0 and 40 degrees demonstrated lower rates of distal junctional kyphosis and higher odds of meeting optimal outcome(OR: 4.2, P =0.011). The best third step was the correction of cSVA below 35 mm. This hierarchical approach (11% of the cohort) led to significantly lower rates of DJF (0% vs. 15%, P <0.007), reoperation (8% vs. 28%, P <0.001), and higher rates of meeting optimal outcome (93% vs. 36%, P <0.001) when controlling for age, comorbidities, and baseline deformity and disability., Conclusion: Our results indicate that the correction of C2 slope should be prioritized during cervical deformity surgery, with the selection of a stable LIV and correction of cervical SVA below the idealized threshold. Among the numerous radiographic parameters considered during preoperative planning for cervical deformity correction, our determinations help surgeons prioritize those realignment strategies that maximize the health-related quality of life outcomes and minimize complications., Level of Evidence: Level-III., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths of stay, and mortality., Purpose: To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery., Study Design/setting: A prospective randomized controlled trial., Materials and Methods: Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes., Results: One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P <0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P <0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P =0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P =0.04)., Conclusions: Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery., Level of Evidence: I., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Previously promising short-term H-Wave ® device stimulation (HWDS) outcomes prompted this retrospective cohort study of the longer-term effects on legacy workers' compensation chronic pain claimants. A detailed chart-review of 157 consecutive claimants undergoing a 30-day HWDS trial (single pain management practice) from February 2018 to November 2019 compiled data on pain, restoration of function, quality of life (QoL), and polypharmacy reduction into a summary spreadsheet for an independent statistical analysis. Non-beneficial trials in 64 (40.8%) ended HWDS use, while 19 (12.1%) trial success charts lacked adequate data for assessing critical outcomes. Of the 74 final treatment study group charts, missing data points were removed for a statistical analysis. Pain chronicity was 7.8 years with 21.6 ± 12.2 months mean follow-up. Mean pain reduction was 35%, with 89% reporting functional improvement. Opioid consumption decreased in 48.8% of users and 41.5% completely stopped; polypharmacy decreased in 36.8% and 24.4% stopped. Zero adverse events were reported and those who still worked usually continued working. An overall positive experience occurred in 66.2% ( p < 0.0001), while longer chronicity portended the risk of trial or treatment failure. Positive outcomes in reducing pain, opioid/polypharmacy, and anxiety/depression, while improving function/QoL, occurred in these challenging chronic pain injury claimants. Level of evidence: III.

Background: Patients with less severe adult spinal deformity (ASD) undergo surgical correction and often achieve good clinical outcomes. However, it is not well understood how much clinical improvement is due to sagittal correction rather than treatment of the spondylotic process., Purpose: Determine baseline thresholds in radiographic parameters that, when exceeded, may result in substantive clinical improvement from surgical correction., Study Design: Retrospective., Materials and Methods: ASD patients with BL and two-year data were included. Parameters assessed: sagittal vertical axis, pelvic incidence-lumbar lordosis mismatch, pelvic tilt, T1 pelvic angle, L1 pelvic angle, L4-S1 lordosis, C2-C7 sagittal vertical axis, C2-T3, C2 slope. Outcomes: Good Outcome (GO) at two years: [meeting either: (1) Substantial Clinical Benefit for Oswestry Disability Index (change >18.8), or (2) Oswestry Disability Index <15 and Scoliosis Research Society Total>4.5]. Binary logistic regression assessed each parameter to determine if correction was more likely needed to achieve GO. Conditional inference tree run machine learning analysis generated baseline thresholds for each parameter, above which, correction was necessary to achieve GO., Results: We included 431 ASD patients. There were 223 (50%) that achieved a GO by two years. Binary logistic regression analysis demonstrated, with increasing baseline severity in deformity, sagittal correction was more often seen in those achieving GO for each parameter(all P <0.001). Of patients with baseline T1 pelvic angle above the threshold, 95% required correction to meet GO (95% vs. 54%, P <0.001). A baseline pelvic incidence-lumbar lordosis >10° (74% of patients meeting GO) needed correction to achieve GO (odds ratio: 2.6, 95% confidence interval: 1.4-4.8). A baseline C2 slope >15° also necessitated correction to obtain clinical success (odds ratio: 7.7, 95% confidence interval: 3.7-15.7)., Conclusions: Our study highlighted point may be present at which sagittal correction has an outsized influence on clinical improvement, reflecting the line where deformity becomes a significant contributor to disability. These new thresholds give us insight into which patients may be more suitable for sagittal correction, as opposed to intervention for the spondylotic process only, leading to a more efficient utility of surgical intervention for ASD., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations., Research Question: Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease?, Materials and Methods: Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses., Results: 47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m 2 ). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001)., Discussion and Conclusion: Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated., Level of Evidence: Level III., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Study Design: Retrospective cohort study., Objective: Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time., Summary of Background Data: As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown., Materials and Methods: Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time., Results: A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03)., Conclusion: Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques., Competing Interests: International Spine Study Group reports conflicts of interest from NuVasive, and SI Bone. Past conflicts include DePuy Synthes, K2M, Stryker, Biomet, Allosource, and Orthofix. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD., Methods: ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders., Results: A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005)., Conclusion: Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity.Cite this article: Bone Joint J  2022;104-B(11):1249-1255.