The Clinical Impact of Failing to Achieve Ideal Proportional Realignment in Adult Spinal Deformity Patients

Passias, Peter G.; Passfall, Lara; Williamson, Tyler; Schoenfeld, Andrew J.; Owusu-Sarpong, Stephane; Dhillon, Ekamjeet S.; Krol, Oscar; Kummer, Nicholas; Tretiakov, Peter; Imbo, Bailey; Joujon-Roche, Rachel; Moattari, Kevin; Lebovic, Jordan; Vira, Shaleen; Diebo, Bassel G.; Smith, Justin S.; Park, Paul; Mummaneni, Praveen V.; Shabani, Saman; Chou, Dean; Lafage, Renaud; Lafage, Virginie

doi:10.1097/brs.0000000000004337

Cited by 11 publications

(14 citation statements)

References 23 publications

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“…Specifically, we observed an increased risk in PJF rates in severely disproportioned patients, which supports earlier work in this area. 12,17,26 Our findings are also aligned with those of Yagi et al, 27 which suggested that at 2 years postoperatively, GAP-SD patients were at greatest risk of complications, including PJF.…”

Section: Discussionsupporting

confidence: 88%

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

Passias¹,

Krol²,

Owusu-Sarpong³

et al. 2023

Operative Neurosurgery

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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.

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Section: Discussionsupporting

confidence: 88%

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

Passias¹,

Krol²,

Owusu-Sarpong³

et al. 2023

Operative Neurosurgery

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“…General enrolment criteria and definition of ASD for this dataset have been described in previous publications, which have also used this cohort to study aspects of clinical management and healthcare policy in the setting of spinal deformity. 8,9 The inclusion criteria of the present work required patients with ASD who were to undergo surgery to have complete demographic and surgical data at enrolment, as well as radiological, clinical, and patientreported outcome data, and complications for at least two years postoperatively. Data collection and radiological assessment.…”

Section: Methodsmentioning

confidence: 99%

Assessing the influence of modifiable patient-related factors on complication rates after adult spinal deformity surgery

Williamson

Passfall

Ihejirika-Lomedico

et al. 2022

The Bone & Joint Journal

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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.

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“…Institutional review board approval was obtained before enrollment and all patients provided informed consent. General enrollment criteria and definition of ASD for this dataset have been described in previous publications, which have also effectively used this cohort to study aspects of clinical management and healthcare policy in the setting of spinal deformity 11,12. All patients included featured a diagnosis of spondylosis or degenerative disk disease present in the thoracolumbar spine.…”

Section: Methodsmentioning

confidence: 99%

“…General enrollment criteria and definition of ASD for this dataset have been described in previous publications, which have also effectively used this cohort to study aspects of clinical management and healthcare policy in the setting of spinal deformity. 11,12 All patients included featured a diagnosis of spondylosis or degenerative disk disease present in the thoracolumbar spine. The inclusion criteria of the present work required operative ASD patients with complete demographic and surgical data at baseline, as well as radiographic, clinical, complications and patientreported outcomes data up to at least two years postoperatively.…”

Section: Data Source and Study Designmentioning

confidence: 99%

Crossing the Bridge from Degeneration to Deformity: When Does Sagittal Correction Impact Outcomes in Adult Spinal Deformity Surgery?

Williamson

Krol

Tretiakov

et al. 2022

Spine

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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.

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The Clinical Impact of Failing to Achieve Ideal Proportional Realignment in Adult Spinal Deformity Patients

Cited by 11 publications

References 23 publications

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

Assessing the influence of modifiable patient-related factors on complication rates after adult spinal deformity surgery

Crossing the Bridge from Degeneration to Deformity: When Does Sagittal Correction Impact Outcomes in Adult Spinal Deformity Surgery?

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