Emily Miller

The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study

BACKGROUND CONTEXT The incidence of proximal junctional kyphosis (PJK) ranges from 5% to 46% following adult spinal deformity surgery. Approximately 66% to 76% of PJK occurs within 3 months of surgery. A subset of these patients, reportedly 26% to 47%, develop proximal junctional failure (PJF) within 6 months postoperatively. To date, there are no studies evaluating the impact of prophylactic vertebroplasty on PJK and PJF incidence at long-term follow-up. PURPOSE The purpose of this study is to evaluate the long-term radiographic and clinical outcomes, and incidence of PJK and PJF, after prophylactic vertebroplasty for long-segment thoracolumbar posterior spinal fusion (PSF). STUDY DESIGN This is a prospective cohort study. PATIENT SAMPLE Thirty-nine patients, of whom 87% were female, who underwent two-level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF were included in this study. OUTCOME MEASURES Clinical outcomes were assessed using the Scoliosis Research Society-22 (SRS-22), and Short-Form (SF) 36 questionnaires, and the Oswestry Disability Index (ODI). Radiographic parameters including PJK angle, and coronal and sagittal alignment, were calculated, along with relevant perioperative complications and revision rates. METHODS Of the 41 patients who received two-level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF, and comprised a cohort with previously published 2-year follow-up data, 39 (95%) completed 5-year follow-up (average: 67.6 months). Proximal junctional kyphosis was defined as a change in the PJK angle ≥10° between the immediate postoperative and final follow-up radiograph. Proximal junctional failure was defined as acute proximal junctional fracture, fixation failure, or kyphosis requiring extension of fusion within the first 6 months postoperatively. RESULTS Thirty-nine patients with a mean age of 65.6 (41-87) years were included in this study. Of the 39 patients, 28.2% developed PJK (11: 7.7% at 2 years, 20.5% between 2 and 5 years), and 5.1% developed acute PJF. Two of the 11 PJK patients required revision for progressive worsening of the PJK. There were no proximal junctional fractures. There was no significant difference in preoperative, immediate postoperative, and final follow-up measurements of thoracic kyphosis, lumbar lordosis, and coronal or sagittal alignment between patients who developed PJK, PJF, or neither (p>.05). There was no significant difference in ODI, SRS-22, or SF-36 scores between those with and without PJK or PJF (p>.05). CONCLUSIONS This long-term follow-up demonstrates that prophylactic vertebroplasty may minimize the risk for junctional failure in the early postoperative period. However, it does not appear to decrease the incidence of PJK at 5 years.

Barriers to Women Entering the Field of Orthopedic Surgery.

The movement toward official academic training for medical professionals in the 12th and 13th centuries led to the exclusion of women from professional health care because they were excluded from universities.1-3 Although women were barred from the practice of surgery, they were able to fill roles as bonesetters. The treatment of musculoskeletal conditions was largely the domain of bonesetters in the centuries before the 1850s. After the advent of anesthesia and antibiotics, the profession of orthopedic surgery developed rapidly, and the bonesetters slowly disappeared. After passage of the 1972 Education Amendments to the Civil Rights Act in the United States, including Title IX4 on sex-based discrimination, the number of female graduates from medical schools began increasing at a steady rate, tripling by 1980.5 However, the percentage of women in surgery lagged behind that in medicine: in 1980, 12% of physicians, but only 2% of surgeons, were women.6 Notably, the percentage of female residents in orthopedic surgery grew at a slower rate than that in other surgical subspecialties (Table 1).6,7 This editorial takes a historical perspective to investigate the key barriers to attracting women to the field. We distributed a survey that focused on exposure to orthopedic surgery to all members of the Ruth Jackson Orthopaedic Society. Of the 777 members, 267 (34%) female orthopedic surgeons and residents responded (Table 2). This represents approximately 20% of all female orthopedic surgeons. Seven personal oral history interviews were conducted with Drs Liebe Diamond (who completed residency in the 1950s), Michelle James (1980s), Mary O’Connor (1980s), Beth Shubin Stein (1990s), Dawn LaPorte (2000), Casey Humbyrd (2010s), and Julia Smart (2010s). Previous research has shown that women’s performance in orthopedic residency programs equals that of men,8 and that women are accepted into orthopedic surgery residency programs at the same rate as men.9 However, women are more underrepresented in orthopedics than in any other specialty. The authors are from the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Dawn M. LaPorte, MD, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Fl 5, Baltimore, MD 21205 (editorialservices@jhmi.edu). doi: 10.3928/01477447-20150902-03 Table 1

Assessment of a Novel Adult Cervical Deformity Frailty Index as a Component of Preoperative Risk Stratification

OBJECTIVE To determine the value of a novel adult cervical deformity frailty index (CD-FI) in preoperative risk stratification. METHODS We reviewed a prospective, multicenter database of adults with cervical spine deformity. We selected 40 variables to construct the CD-FI using a validated method. Patients were categorized as not frail (NF) (<0.2), frail (0.2-0.4), or severely frail (SF) (>0.4) according to CD-FI score. We performed multivariate logistic regression to determine the relationships between CD-FI score and incidence of complications, length of hospital stay, and discharge disposition. RESULTS Of 61 patients enrolled from 2009 to 2015 with at least 1 year of follow-up, the mean CD-FI score was 0.26 (range 0.25-0.59). Seventeen patients were categorized as NF, 34 as frail, and 10 as SF. The incidence of major complications increased with greater frailty, with a gamma correlation coefficient of 0.25 (asymptotic standard error, 0.22). The odds of having a major complication were greater for frail patients (odds ratio 4.4; 95% confidence interval 0.6-32) and SF patients (odds ratio 43; 95% confidence interval 2.7-684) compared with NF patients. Greater frailty was associated with a greater incidence of medical complications and had a gamma correlation coefficient of 0.30 (asymptotic standard error, 0.26). Surgical complications, discharge disposition, and length of hospital stay did not correlate significantly with frailty. CONCLUSIONS Greater frailty was associated with greater risk of major complications for patients undergoing cervical spine deformity surgery. The CD-FI may be used to improve the accuracy of preoperative risk stratification and allow for adequate patient counseling.

Morbidity of Adult Spinal Deformity Surgery in Elderly Has Declined Over Time

Study Design. A retrospective review of a prospectively collected database, the Nationwide Inpatient Sample (NIS), years 2003 to 2012. Objectives. The aim of this study was to examine trends in the management of scoliosis in elderly (age >75 yrs) patients from 2003 to 2012. Summary of Background Data. Scoliosis incidence rises with increasing age, and age has been shown to be an independent risk factor for surgical complications in scoliosis surgery. Previous studies have displayed increasing surgical frequency on elderly scoliotic patients in the last decade, but have not investigated complications in the same years. Methods. ICD-9 coding identified elderly (age ≥75 yrs) patients with a primary diagnosis of scoliosis undergoing lumbar fusion or decompression. Analysis of variance (ANOVA) comparisons and linear trend analysis described changes from 2003 to 2012 in surgical invasiveness (Mirza scale: levels fused/decompressed/instrumented and by approach), intraoperative complications, and Charlson Comorbidity Index (CCI). Secondary outcome measures included cost and discharge outcomes. Results. Eight thousand one elderly patients with ASD from 2003 to 2012 were included for analysis. Fusion incidence increased on average 13.8% per year (P < 0.001), surgical invasiveness by Mirza scale increased from 2.0 in 2003 to 5.9 in 2012 (P < 0.001), and CCI increased from 0.77 to 1.44 (p < 0.001). Over the same interval, elderly patients undergoing fusion displayed overall reduction in complications (excluding anemia)—from 26.7% to 8.6% (P < 0.001); specifically, surgical complications decreased from 11.7% to 0.7% (P < 0.001) and respiratory complications decreased from 6.7% to 1.4% (P = 0.004). Conclusion. From 2003 to 2012, surgical management of ASD in the elderly population increased in incidence and complexity, while number of patient comorbidities increased and in-hospital morbidity decreased. This may indicate increased willingness of surgeons to operate on elderly patients, and reflect a development of overall understanding of deformity in the past decade. Level of Evidence: 3

An assessment of frailty as a tool for risk stratification in adult spinal deformity surgery

OBJECTIVE The goal of this study was to analyze the value of an adult spinal deformity frailty index (ASD-FI) in preoperative risk stratification. Preoperative risk assessment is imperative before procedures known to have high complication rates, such as ASD surgery. Frailty has been associated with risk of complications in trauma surgery, and preoperative frailty assessments could improve the accuracy of risk stratification by providing a comprehensive analysis of patient factors that contribute to an increased risk of complications. METHODS Using 40 variables, the authors calculated frailty scores with a validated method for 417 patients (enrolled between 2010 and 2014) with a minimum 2-year follow-up in an ASD database. On the basis of these scores, the authors categorized patients as not frail (NF) (< 0.3 points), frail (0.3-0.5 points), or severely frail (SF) (> 0.5 points). The correlation between frailty category and incidence of complications was analyzed. RESULTS The overall mean ASD-FI score was 0.33 (range 0.0-0.8). Compared with NF patients (n = 183), frail patients (n = 158) and SF patients (n = 109) had longer mean hospital stays (1.2 and 1.6 times longer, respectively; p < 0.001). The adjusted odds of experiencing a major intraoperative or postoperative complication were higher for frail patients (OR 2.8) and SF patients ( 4.1) compared with NF patients (p < 0.01). For frail and SF patients, respectively, the adjusted odds of developing proximal junctional kyphosis (OR 2.8 and 3.1) were higher than those for NF patients. The SF patients had higher odds of developing pseudarthrosis (OR 13.0), deep wound infection (OR 8.0), and wound dehiscence (OR 13.4) than NF patients (p < 0.05), and they had 2.1 times greater odds of reoperation (p < 0.05). CONCLUSIONS Greater patient frailty, as measured by the ASD-FI, was associated with worse outcome in many common quality and value metrics, including greater risk of major complications, proximal junctional kyphosis, pseudarthrosis, deep wound infection, wound dehiscence, reoperation, and longer hospital stay.

Patient and operative factors associated with complications following adolescent idiopathic scoliosis surgery: an analysis of 36,335 patients from the Nationwide Inpatient Sample

OBJECTIVE The aim of this study was to investigate the incidence of and factors associated with complications following idiopathic scoliosis surgery in adolescents. METHODS The Nationwide Inpatient Sample database was used to identify patients 10-18 years of age who had undergone spinal fusion for adolescent idiopathic scoliosis (AIS) from 2002 to 2011. Twenty-three unique in-hospital postoperative complications, including death, were examined. A series of logistic regressions was used to determine if any demographic, comorbid, or surgical parameter was associated with complication development. Results of multiple logistic regression analyses were reported as odds ratios with 95% confidence intervals. All analyses were performed after the application of discharge weights to produce national estimates. RESULTS A total of 36,335 patients met the study inclusion criteria, 7.6% of whom (95% CI 6.3%-8.9%) developed at least one in-hospital complication. The 3 most common complications were respiratory failure (3.47%), reintubation (1.27%), and implant related (1.14%). Major complications such as death, pancreatitis, disseminated intravascular coagulation, visual loss, spinal cord injury, cardiac arrest, sepsis, nerve root injury, deep vein thrombosis, pulmonary embolism, shock, malignant hyperthermia, myocardial infarction, and iatrogenic stroke each had an incidence ≤ 0.2%. On multiple logistic regression analysis, an increasing age (OR 0.80) was associated with significantly lower odds of complication development; patients who were male (OR 1.80) or who had anemia (OR 2.10), hypertension (OR 2.51), or hypothyroidism (OR 2.27) or underwent revision procedures (OR 5.55) were at a significantly increased risk for complication development. The rates of postoperative complications for posterior, anterior, and combined approaches were 6.7%, 10.0%, and 19.8%, respectively (p < 0.001). Length of fusion (< 8 vs ≥ 8 levels) was not associated with complication development (p = 0.311). CONCLUSIONS Analysis of 36,335 patients who had undergone surgery for AIS revealed that younger patients, male patients, patients with a history of anemia, hypertension, or hypothyroidism, as well as those undergoing revision or anterior or combined approaches may have higher rates of postoperative complications. However, the overall complication rate was low (7.6%), and major complications had a rate ≤ 0.2% for each event. These findings suggest that surgery for AIS remains relatively safe, and future prospective investigations may further help to decrease the postoperative morbidity rate.

Predictive Modeling of Length of Hospital Stay Following Adult Spinal Deformity Correction: Analysis of 653 Patients with an Accuracy of 75% within 2 Days

BACKGROUND Length of stay (LOS) after surgery for adult spinal deformity (ASD) is a critical period that allows for optimal recovery. Predictive models that estimate LOS allow for stratification of high-risk patients. METHODS A prospectively acquired multicenter database of patients with ASD was used. Patients with staged surgery or LOS >30 days were excluded. Univariable predictor importance ≥0.90, redundancy, and collinearity testing were used to identify variables for model building. A generalized linear model was constructed using a training dataset developed from a bootstrap sample; patients not randomly selected for the bootstrap sample were selected to the training dataset. LOS predictions were compared with actual LOS to calculate an accuracy percentage. RESULTS Inclusion criteria were met by 653 patients. The mean LOS was 7.9 ± 4.1 days (median 7 days; range, 1-28 days). Following bootstrapping, 893 patients were modeled (653 in the training model and 240 in the testing model). Linear correlations for the training and testing datasets were 0.632 and 0.507, respectively. The prediction accuracy within 2 days of actual LOS was 75.4%. CONCLUSIONS Our model successfully predicted LOS after ASD surgery with an accuracy of 75% within 2 days. Factors relating to actual LOS, such as rehabilitation bed availability and social support resources, are not captured in large prospective datasets. Predictive analytics will play an increasing role in the future of ASD surgery, and future models will seek to improve the accuracy of these tools.

Pregnancy-related ligamentous laxity mimicking dynamic scapholunate instability: A case report

Case: A 29-year-old woman presented with spontaneous, isolated, total palmar scaphoid subluxation in the left hand approximately 6 weeks postpartum. She had a positive Watson scaphoid shift test, with an easily subluxable and reducible scaphoid unilaterally. She was diagnosed with scapholunate ligamentous laxity with dynamic instability. Approximately 4 months after stopping lactation, she had complete resolution of the scapholunate subluxation; there was no recurrence of symptoms over the next 5 years of follow-up. Conclusion: Women can have manifestations of pregnancy and lactation-related ligamentous laxity, including scapholunate instability, which may spontaneously resolve upon cessation of lactation.