Doug Burton

Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients.

Study Design. Multi-center, retrospective review. Objective. Identify age associated clinical and radiographic features correlating with AS treatment. Summary of Background Data. Little information exists about factors determining treatment for adult scoliosis (AS). Existing studies have not evaluated age stratified differences. Methods. Multicenter, retrospective review of 290 patients treated for AS. Patients divided into operative (OP) or nonoperative (NON), and age stratified into 3 groups (G1 = <50 years, G2 = 50–65 years, G3 = >65 years). Demographic and spinopelvic radiographic parameters evaluated. Health-related quality of life (HRQL) measures included SRS-22, Oswestry Disability Index (ODI), visual analog pain scale. Results. Treatment groups (OP, n = 137; NON, n = 153) demonstrated similar age (OP = 52.7 years; NON = 55.5 years; P > 0.05) and cormorbidities. OP had larger thoracic curves than NON (OP = 51°, NON = 45°; P < 0.05). OP had worse HRQL scores than NON (SRS = 2.95 vs. 3.12, P < 0.05; ODI = 33.4 vs. 28.7, P < 0.05; visual analog pain scale = 6.9 vs. 5.6, P < 0.05, respectively). Age stratification of OP demonstrated larger curves in G1 and G2 versus G3, progressively worsening sagittal imbalance in older age groups, and worse HRQL scores in G3 versus G1 and G2. Age stratification of NON demonstrated worsening sagittal imbalance with age, however, other radiographic values and HRQL scores were similar between all NON age groups. Treatment stratification of age groups demonstrated G1-OP had greater deformity than G1-NON (mean thoracic curve: G1-OP = 53°, G1-NON = 43°; P < 0.05) but similar HRQL values. Whereas G2 and G3-OP had similar radiographic coronal and sagittal values as G2 and G3-NON, but worse HRQL scores. Conclusion. Counter to previous reports, age, cormorbidities, and sagittal balance did not influence treatment modality for AS. Operative treatment for younger patients was driven by increased coronal plane deformity. Conversely, pain and disability mandated treatment for olderpatients, independent of radiographic measures. These findings suggest that AS patients do not become uniformly disabled with age, and that disability can not be solely predicted by radiographic findings. These data should be considered when considering treatment for AS.

The influence of spine and trunk deformity on preoperative idiopathic scoliosis patients' health-related quality of life questionnaire responses.

Study Design. Retrospective case series. Objectives. To determine the influence of spine and trunk deformity on preoperative idiopathic scoliosis patients’ health-related quality of life questionnaire responses. Summary of Background Data. Management recommendations for patients with idiopathic scoliosis during adolescence are based heavily on spine deformity and to some extent trunk deformity magnitude. However, the manner in which these objective measures influence the patients’ perception of their condition is unclear. Methods. Of 67 consecutive preoperative patients, 61 (91%) had completed the Scoliosis Research Society-22 health-related quality of life questionnaire and had been studied with posterior exposure surface topography. Their average age was 15 years, 6 months (range 10 years, 10 months–20 years, 10 months), and the average maximum Cobb was 63° (range 40–137°). Correlations between spine and trunk deformity measures and Scoliosis Research Society-22 scores were determined by the Pearson correlation coefficient, with P < 0.01 considered significant. Results. For the study group, spine deformity (Cobb) correlated significantly only with Scoliosis Research Society-22 function (r = −0.39, P = 0.0022) domain. Neither coronal nor transverse plane trunk deformity composite scores correlated with any Scoliosis Research Society-22 scores. The Hump Index component of the transverse plane Suzuki Hump Sum composite score was the only trunk measurement to correlate significantly (function r = −0.45, P = 0.003; self image, r = −0.36, P = 0.0040). The strongest correlations occurred when the single thoracic curves, King classifications III and IV, were combined: Cobb versus function r = −0.53, P = 0.0027; Cobb versus self-image r = −0.46, P = 0.0099; and Hump Index versus function r = −0.60, P = 0.0005. There were no significant correlations between either spine deformity or any trunk deformity measure with Scoliosis Research Society-22 responses for either the double or thoracolumbar curve pattern groups. Conclusion. Both spine and upper thoracic transverse plane trunk deformity significantly influenced preoperative idiopathic scoliosis patients’ perception of function and self-image, but not pain or mental health. However, in spite of a fairly rigorous standard of proof, P ≤ 0.01, the significant r values ranged from −0.33 to −0.68, suggesting that there are factors other than spine and trunk deformity influencing the idiopathic scoliosis patients’ health-related quality of life questionnaire responses. Future studies are necessary to define these factors.

Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity.

Study Design. Multicenter, retrospective series. Objective. To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity. Summary of Background Data. Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear. Methods. A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery. Results. Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26–82 yr), mean fusion levels of 9.8 (range, 4–18), and mean time to APJF of 11.4 weeks (range, 1.5–28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01). Conclusion. APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.

Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity: A Prospective, Multicenter, Propensity-Matched Cohort Assessment With Minimum 2-Year Follow-up

BACKGROUND High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed. OBJECTIVE To compare outcomes of operative and nonoperative treatment for ASD. METHODS This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence-to-lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up. RESULTS Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence-to-lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications. CONCLUSION Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability. ABBREVIATIONS ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisMCID, minimal clinically important differenceNRS, numeric rating scaleODI, Oswestry Disability IndexPI, pelvic incidenceSF-36, Short Form-36SRS-22r, Scoliosis Research Society-22rSVA, sagittal vertical axis.

Identification of decision criteria for revision surgery among patients with proximal junctional failure after surgical treatment of spinal deformity

Study Design. Multicenter, retrospective, consecutive case series. Objective. This study aims to identify demographic and radiographical characteristics that influence the decision to perform revision surgery among patients with proximal junctional failure (PJF). Summary of Background Data. Revision rates after PJF remain relatively high, yet the decision criteria for performing revision surgical procedures are not uniform and vary by surgeon. A better understanding of the factors that impact the decision to perform revision surgery is important in order to improve efficiency of surgical treatment of adult spinal deformity. Methods. A cohort of 57 patients with PJF was identified retrospectively from 1218 consecutive patients with adult spinal deformity. PJF was identified on the basis of 10° postoperative increase in kyphosis between upper instrumented vertebra (UIV) and UIV +2, along with 1 or more of the following: fracture of the vertebral body of UIV or UIV +1, posterior osseoligamentous disruption, or pullout of instrumentation at the UIV. Univariate statistical analysis was performed using t tests and Fisher exact tests. Multivariate analysis was performed using logistic regression. Results. Twenty-seven (47.4%) patients underwent revision surgery within 6 months of the index operation. Regression results revealed that patients with combined posterior/anterior approaches at index were significantly more likely to undergo revision (P = 0.001) as were patients with more extreme proximal junctional kyphosis angulation (P = 0.034). Patients sustaining trauma were also significantly more likely to undergo revision (P = 0.019). Variables approaching but not reaching significance as predictors of revision included female sex (P = 0.066) and higher sagittal vertical axis (SVA) (P = 0.090). Conclusion. The decision to perform revision surgery is complicated and varies by surgeon. Factors that seem to influence this decision include traumatic etiology of PJF, severity of proximal junctional kyphosis angulation, higher SVA, and female sex. Factors that were expected to influence revision but had no statistical effect included soft tissue versus bony mode of failure, age, levels fused, and upper thoracic versus thoracolumbar proximal junction. Level of Evidence: 2

Functional limitations due to lumbar stiffness in adults with and without spinal deformity

Study Design. Cross-sectional analysis. Objective. To compare Lumbar Stiffness Disability Index (LSDI) scores between asymptomatic adults and patients with spinal deformity. Summary of Background Data. The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. Baseline disability levels of patients with adult spinal deformity (ASD) are high as measured by multiple validated outcome tools. Baseline lumbar stiffness-related disability has not been assessed in adults with and without spinal deformity. Methods. The LSDI and Scoliosis Research Society-22r (SRS-22r) were submitted to a group of asymptomatic adult volunteers. Additionally, a multicenter cross-sectional cohort analysis of patients with ASD from 10 centers was conducted. Baseline LSDI and SRS-22r were completed for both operatively and nonoperatively treated patients with deformity. Results. The LSDI was completed by 176 asymptomatic volunteers and 693 patients with ASD. Mean LSDI score for asymptomatic volunteers was 3.4 +/− 6.3 out of a maximum score of 100, with significant correlation between increasing age and higher (worse) LSDI score (r = 0.30, P = 0.0001). Of the patients with spinal deformity undergoing analysis, 301 subsequently underwent surgery and 392 were subsequently treated nonoperatively. Operative patients had significantly higher preoperative LSDI scores than both nonoperative patients and asymptomatic volunteers (29.9 vs. 17.3 vs. 3.4, P < 0.0001 for both). For patients with ASD, significant correlations were found between LSDI and SRS-22 Pain and Function subscales (r = −0.75 and −0.76, respectively; P < 0.0001 for both). Conclusion. LSDI scores are low among asymptomatic volunteers, although stiffness-related disability increases with increasing age. Patients with ASD report substantial stiffness-related disability even prior to surgical fusion. Stiffness-related disability correlates with pain- and function-related disability measures among patients with spinal deformity. Level of Evidence: 1

The Health Impact of Adult Cervical Deformity in Patients Presenting for Surgical Treatment: Comparison to United States Population Norms and Chronic Disease States Based on the EuroQuol-5 Dimensions Questionnaire

BACKGROUND: Although adult cervical spine deformity (ACSD) is associated with pain and disability, its health impact has not been quantified in comparison to other chronic diseases. OBJECTIVE: To perform a comparative analysis of the health impact of symptomatic ACSD to US normative and chronic disease values using EQ‐5D (EuroQuol‐5 Dimensions questionnaire) scores. METHODS: ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Baseline demographics and EQ‐5D scores were collected and compared with US normative and disease state values. RESULTS: Of 121 ACSD patients, 115 (95%) completed the EQ‐5D (60% women, mean age 61 years, previous spine surgery in 44%). Diagnoses included kyphosis with mid‐cervical (63.4%), cervico‐thoracic (23.5%), or thoracic (8.7%) apex and primary coronal deformity (4.3%). The mean ACSD EQ‐5D index was 0.511 (standard definition = 0.224), which is 34% below the bottom 25th percentile (0.780) for similar age‐ and gender‐matched US normative populations. Mean ACSD EQ‐5D index values were worse than the bottom 25th percentile for several other disease states, including chronic ischemic heart disease (0.708), malignant breast cancer (0.708), and malignant prostate cancer (0.708). ACSD mean index values were comparable to the bottom 25th percentile values for blindness/low vision (0.543), emphysema (0.508), renal failure (0.506), and stroke (0.463). EQ‐5D scores did not significantly differ based on cervical deformity type (P = .66). CONCLUSION: The health impact of symptomatic ACSD is substantial, with negative impact across all EQ‐5D domains. The mean ACSD EQ‐5D index was comparable to the bottom 25th percentile values for blindness/low vision, emphysema, renal failure, and stroke.

Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database

BACKGROUND CONTEXT Adult spinal deformity (ASD) surgery is associated with significant resource utilization, costing more than

Comparison of Best Versus Worst Clinical Outcomes for Adult Cervical Deformity Surgery

958 million in charges for Medicare patients and more than

The Reliability and Concurrent Validity of the Scoliosis Research Society-22 Patient Questionnaire for Idiopathic Scoliosis

1.7 billion in charges for managed care population in the last decade. Given the recent move toward bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component toward the bundled payment. PURPOSE To examine the degree and determinants of variation in inpatient episode-of-care (EOC) cost, resource utilization, and patient-reported outcomes for patients undergoing ASD surgery across four spine deformity centers in the United States. STUDY DESIGN/SETTING Retrospective analysis of prospective, multicenter database. PATIENT SAMPLE Consecutive patients enrolled in an ASD database from four spinal deformity centers. OUTCOME MEASURES Total in-patient EOC costs and Short Form (SF)-6D. METHODS The study used a multicenter database of 210 consecutively enrolled operative patients from 2008 to 2013 at four participating centers in the United States. Demographic, surgical, and direct cost data, expressed in 2013 dollars, for the entire inpatient EOC were obtained from administrative databases from the respective hospitals. Mixed models and multivariable linear regression were used to evaluate the impact of center on total costs adjusting for patient characteristics, length of stay (LOS), and surgical factors. RESULTS A total of 126 patients with complete baseline and 2-year follow-up data were included. The percentages of patients from each center were 36.5%, 7.1%, 24.6%, and 31.7%. Overall, the mean patient age was 58.4±12.6 years, 86% were women, and 94% were Caucasian. The proportion of total cost variation explained by the center at which the patient was treated was 17%. After adjusting for patient, LOS, and surgical factors the cost variation reduced to 4%. In multivariable analysis, each additional level fused increased total cost variation by