Lukas P. Zebala

Does Treatment (Nonoperative and Operative) Improve the Two-Year Quality of Life in Patients With Adult Symptomatic Lumbar Scoliosis: A Prospective Multicenter Evidence-Based Medicine Study

Study Design. Prospective observational cohort study with matched and unmatched comparisons. Level II evidence. Objective. The purpose of this study is to compare results of adult symptomatic lumbar scoliosis (ASLS) patients treated nonoperatively and operatively. This is an evidence-based prospective multicenter study to answer the question of whether nonoperative and operative treatment improves the quality of life (QOL) in these patients at 2-year follow-up. Summary of Background Data. Only 1 paper in the peer-reviewed published data directly addresses this question. That paper suggested that operative treatment was more beneficial than nonoperative care, but the limitations relate to historical context (all patients treated with Harrington implants) and the absence of validated patient-reported QOL (QOL) data. Methods. This study assesses 160 consecutively enrolled patients (ages 40–80 years) with baseline and 2-year follow-up data from 5 centers. Lumbar scoliosis without prior surgical treatment was defined as a minimum Cobb angle of 30° (mean: 54° for patients in this study). All patients had either an Oswestry Disability Index (ODI) score of 20 or more (mean: 33) or Scoliosis Research Society (SRS) domain scores of 4 or less in pain, function, and self-image (mean: 3.2) at baseline. Pretreatment and 2-year follow-up data collected prospectively included basic radiographic parameters, complications and SRS QOL, ODI, and Numerical Rating Scale back and leg pain scores. Results. At 2 years, follow-up on the operative patients was 95% and for the nonoperative patients it was 45%.The demographics for the nonoperative patients who were followed up for 2 years versus those who were lost to follow-up were identical. The operative cohort significantly improved in all QOL measures. The nonoperativecohort did not improve and nonsignificant decline in QOL scores was common. At minimum 2-year follow-up, operative patients outperformed nonoperative patients by all measures. Conclusion. It would appear from this study that common nonoperative treatments do not change the QOL in patients with ASLS at 2-year follow-up. However, operative treatment does significantly improve the QOL for this group of patients. Our conclusions are limited by the fact that we were only able to follow-up 45% of the nonoperative group to 2-year follow-up, in spite of extensive efforts on our part to accomplish such.

Major Complications and Comparison Between 3-column Osteotomy Techniques in 105 Consecutive Spinal Deformity Procedures

Study Design. A retrospective review. Objective. To characterize the risk factors for the development of major complications in 3-column osteotomies and determine whether the presence of a major complication affects ultimate clinical outcomes. Summary of Background Data. Three-column spinal osteotomies, including pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR), are common techniques to correct severe and/or rigid spinal deformities. Methods. Two hundred forty consecutive PSO (n = 156) and VCR (n = 84) procedures in 237 patients were performed at a single institution between 1995 and 2008. Of these, 105 patients (87 PSOs, 18 VCRs) had complete preoperative and minimum 2-year postoperative clinical outcomes data available for analysis. Using established criteria, we reported complications as major or minor and further stratified complications as surgical versus medical and permanent versus transient. Risk factors for complications and their effect on Scoliosis Research Society (SRS) clinical outcomes at baseline and at 2 years or more were assessed. Results. Major medical and surgical complications occurred at similar rates in both PSOs and VCRs (38%, 33 of 87 vs. 22%, 4 of 18; P = 0.28). Overall, 24.8% (26 of 105) experienced major surgical complications (3 permanent) and 15.2% (16 of 105) experienced major medical complications (4 permanent). Patients with PSO were older (53 vs. 29 yr; P < 0.001), had greater estimated blood loss (1867 vs. 1278 mL; P = 0.02), and showed a trend toward fewer fused levels (10.1 vs. 12.2; P = 0.06). Risk factors for major complications included preoperative sagittal imbalance of 40 mm or more (P = 0.01), age 60 years and older (P = 0.01), and the presence of 3 or more medical comorbidities (P = 0.04). Both groups improved significantly from baseline in SRS subscores; however, patients with PSO started off worse but improved more than VCRs in both the pain (+1.0 vs. +0.1; P < 0.001) and function (+0.6 vs. +0.2; P = 0.01) domains, with no differences in final satisfaction (4.1 vs. 4.3; P = 0.54). PSO and VCR patients with no complications had slightly higher satisfaction scores than patients with minor-only complications, major transient complications, and major permanent complications. There were no significant differences among the groups with respect to change in SRS subscores from baseline, and all complication groups improved significantly from baseline (P = 0.04). Conclusion. Major complications occurred in 35% of 3-column osteotomies and at similar rates for both PSO (38%) and VCR (22%) procedures. The presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.

Major complications in revision adult deformity surgery: Risk factors and clinical outcomes with 2- to 7-year follow-up

Study Design. Retrospective cohort comparative study. Objective. To determine the prevalence of major complications, identify risk factors, and assess long-term clinical benefit after revision adult spinal deformity surgery. Summary of Background Data. No study has analyzed risk factors for major complications in long revision fusion surgery and whether or not occurrence of a major complication affects ultimate clinical outcome. Methods. Analysis of consecutive adult patients who underwent multilevel revision surgery for spinal deformity with a minimum 2-year follow-up was performed. All complications were classified as either major or minor. Outcome analysis was conducted with the Scoliosis Research Society and Oswestry Disability Index scores. Results. A total of 166 patients (mean age = 53.8 years) were identified with a mean follow-up of 3.5 years (range: 2–7). Primary diagnoses included idiopathic/de novo scoliosis (107), degenerative (35), trauma (7), neuromuscular scoliosis (6), congenital deformity (5), ankylosing spondylitis (2), tumor (2), Scheuermann kyphosis (1), and rheumatoid arthritis (1). Most common secondary diagnoses that necessitated revision surgery were adjacent segment disease, fixed sagittal imbalance, and pseudarthrosis. Overall, 34.3% of patients developed major complications (19.3% perioperative; 18.7% follow-up). Associated risk factors for perioperative complications were patient- (age > 60 years, medical comorbidities, obesity) and surgery-related (pedicle subtraction osteotomy). Performance of a 3-column osteotomy and postoperative radiographic changes that suggested progressive loss of sagittal correction were recognized as risk factors for follow-up complications. Equivalent outcome scores were reported by patients preoperatively, but those experiencing follow-up complications reported lower scores at the final follow-up. Conclusion. Overall, 34.4% of patients experienced major complications after long revision fusion surgery. Different risk factors were identified for perioperative versus follow-up complications. The occurrence of a follow-up, not but perioperative, major complication seemed to have a negative impact on ultimate clinical outcome.

Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement

BACKGROUND A variety of surgical techniques have been introduced for the treatment of femoroacetabular impingement, but clinical outcome studies of less-invasive treatment with a minimum duration of follow-up of two years are limited. The purpose of this study was to evaluate the early clinical and radiographic outcomes of combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction for the treatment of cam femoroacetabular impingement. METHODS We performed a retrospective review of our first thirty-five patients (thirty-five hips) in whom cam femoroacetabular impingement had been treated with combined hip arthroscopy and limited open osteochondroplasty. Thirty-five patients (twenty-eight men and seven women) with an average age of thirty-four years and a minimum duration of follow-up of two years were analyzed. The modified Harris hip score was utilized to assess hip function. The Tönnis osteoarthritis grade and the alpha angle were determined to assess osteoarthritis progression and deformity correction, respectively. RESULTS The average modified Harris hip score improved from 63.8 points preoperatively to 87.4 points at the time of the last follow-up. Twenty-nine (83%) of the thirty-five patients had at least a 10-point improvement in the Harris hip score, and 71% had a score of >80 points. The average alpha angle was reduced from 58.6 degrees preoperatively to 37.1 degrees at the time of follow-up when measured on cross-table lateral radiographs, from 63.9 degrees to 37.8 degrees when measured on frog-leg lateral radiographs, and from 63.1 degrees to 44.8 degrees when measured on anteroposterior radiographs. Two patients had osteoarthritis progression from Tönnis grade 0 to grade 1. Minor complications included one superficial wound infection, one deep vein thrombosis, and four cases of asymptomatic Brooker grade-I heterotopic ossification. There were no femoral neck fractures or cases of femoral head osteonecrosis, and no hip was converted to an arthroplasty. CONCLUSIONS Early results indicate that combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction is a safe and effective treatment for femoroacetabular impingement. In our small series, most patients had symptomatic relief, improved hip function, and enhanced activity after two years of follow-up.

Methods to decrease postoperative infections following posterior cervical spine surgery.

BACKGROUND To decrease surgical site infections, we initiated a protocol of preliminary preparation of the skin and surrounding plastic drapes with alcohol foam, and the placement of a suprafascial drain in addition to a subfascial drain in obese patients in 2004. In 2008, we additionally placed 500 mg of vancomycin powder into the wound prior to closure. The purpose of this study was to analyze the infection rates for three groups: Group C (control that received standard perioperative intravenous antibiotics alone), Group AD (alcohol foam and drain), and Group VAD (vancomycin with alcohol foam and drain). METHODS A consecutive series of 1001 all-posterior cervical spine surgical procedures performed at one institution by the senior author from 1995 to 2010 was retrospectively reviewed. These surgical procedures included foraminotomy, laminectomy, laminoplasty, arthrodesis, instrumentation, and/or osteotomies. There were 483 patients in Group C, 323 in Group AD, and 195 in Group VAD. RESULTS In Group C, nine (1.86%) of the 483 patients had an acute postoperative deep infection, in which methicillin-resistant Staphylococcus aureus was the most common pathogen. A significantly higher rate of infection was found in patients with an active smoking history (p = 0.008; odds ratio = 2.6 [95% confidence interval, 1.0 to 7.1]), rheumatoid arthritis (p = 0.005; odds ratio = 4.0 [95% confidence interval, 1.4 to 7.9]), and a body mass index of ≥30 kg/m2 (p = 0.005; odds ratio = 4.1 [95% confidence interval, 1.5 to 7.7]). Group AD (n = 323) had one infection, a significant decrease compared with Group C (p = 0.047). In Group VAD, none of the 195 patients had infections, which was also a significant decrease compared with Group C (p = 0.048). CONCLUSIONS In this study, preliminary preparation with alcohol foam and the placement of suprafascial drains for deep wounds resulted in one postoperative deep infection in 323 surgical procedures. The addition of intrawound vancomycin powder in 195 consecutive posterior cervical spine surgical procedures resulted in no infections and no adverse effects. To our knowledge, this is the first description of a technique for significantly decreasing postoperative cervical spine infections.

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.

Proximal Junctional Kyphosis in Primary Adult Deformity Surgery: Evaluation of 20 Degrees as a Critical Angle

BACKGROUND : Multiple studies have reported on the prevalence of proximal junctional kyphosis (PJK) following spinal deformity surgery; however, none have demonstrated its significance with respect to functional outcome scores or revision surgery. OBJECTIVE : To evaluate if 20° is a possible critical PJK angle in primary adult scoliosis surgery patients as a threshold for worse patient-reported outcomes. METHODS : Clinical and radiographic data of 90 consecutive primary surgical patients at a single institution (2002-2007) with adult idiopathic/degenerative scoliosis and 2-year minimum follow-up were analyzed. Assessment included radiographic measurements, but most notably sagittal Cobb angle of the proximal junctional angle at preoperation, between 1 and 2 months, 2 years, and ultimate follow-up. RESULTS : Prevalence of PJK ≥20° at 3.5 years was 27.8% (n = 25). Those with PJK ≥20° at ultimate follow-up were older (mean 56 vs 46 years), had lower number of levels fused (median 8 vs 11), and were proximally fused to the lower thoracic spine more often than upper thoracic spine (all P < .001). PJK ≥20° was associated with significantly higher body mass index and fusion to the sacrum with iliac screws (P < .016, P < .029, respectively). Scoliosis Research Society outcome score changes were lower for PJK patients, but not significantly different from those in the non-PJK group. CONCLUSION : PJK ≥20° in primary adult idiopathic/degenerative scoliosis does not lead to revision surgery for PJK, but is univariately associated with older age, shorter constructs starting in the lower thoracic spine, obesity, and fusion to the sacrum. The negative results, supported by Scoliosis Research Society outcome data, provide important guidance on the postoperative management of such PJK patients. ABBREVIATIONS : BMI, body mass indexLIV, lowest instrumented vertebraeODI, Oswestry Disability IndexPJ, proximal junctionalPJK, proximal junctional kyphosisSRS, Scoliosis Research SocietyUIV, upper instrumented vertebra.

High-dose rhBMP-2 for adults: major and minor complications: a study of 502 spine cases.

BACKGROUND Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) has increased considerably since its introduction in 2002. The complications associated with high-dose rhBMP-2 (≥ 40 mg) are unknown. The purpose of our study was to determine outcomes and medical and surgical complications associated with high-dose rhBMP-2 at short-term and long-term follow-up evaluations. METHODS Five hundred and two consecutive adult patients who had received high-dose rhBMP-2 as a part of spinal surgery from 2002 to 2009 at one institution were enrolled. Data were entered prospectively and studied and analyzed retrospectively. Surgical procedures in the thoracic and lumbar spine were included. Major and minor complications were documented intraoperatively, perioperatively, and at the latest follow-up examination. Complications potentially associated with rhBMP-2 use were evaluated for correlation with rhBMP-2 dose. Scoliosis Research Society (SRS) and Oswestry Disability Index (ODI) outcome measures were obtained before and after surgery. RESULTS On average, 115 mg (range, 40 to 351 mg) of rhBMP-2 was used. The average age of the patients (410 women and ninety-two men) at the time of the index procedure was 52.4 years (range, eighteen to eighty years). There were 265 primary and 237 revision procedures, and 261 patients had interbody fusion. An average of 11.5 vertebrae were instrumented. The average duration of follow-up was forty-two months (range, fourteen to ninety-two months). The diagnoses included idiopathic scoliosis (41%), degenerative scoliosis (31%), fixed sagittal imbalance (18%), and other diagnoses (10%). The rate of intraoperative complications was 8.2%. The rate of perioperative major surgical complications was 11.6%. The rate of perioperative major medical complications was 11.6%. Minor medical complications occurred in 18.9% of the cases, and minor surgical complications occurred in 2.6%. Logistic regression analysis and Pearson correlation did not identify a significant correlation between rhBMP-2 dosage and radiculopathy (r = -0.006), seroma (r = -0.003), or cancer (r = -0.05). Significant improvements in the ODI score (from a mean of 41 points to a mean of 26 points; p < 0.001) and the SRS total score (from a mean of 3.0 points to a mean of 3.7 points; p < 0.001) were noted at the latest follow-up evaluation. CONCLUSIONS This is the largest study of which we are aware that examines complications associated with high-dose rhBMP-2. Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. There was a cancer prevalence of 3.4%, but no correlation between increasing rhBMP-2 dosage and cancer, radiculopathy (seen in 1% of the patients), or seroma (seen in 0.6%) was found.

Comparative analysis of clinical outcome and complications in primary versus revision adult scoliosis surgery

Study Design. A retrospective case comparison study. Objective. We compared clinical outcome and complications in adult patients who underwent primary (P) versus revision (R) scoliosis surgery. Summary of Background Data. There is a paucity of data comparing P versus R adult scoliosis patients with respect to their complication rates and clinical outcome. Methods. Assessment of 250 consecutive adult patients who underwent P versus R surgery for idiopathic or de novo scoliosis between 2002 and 2007, with a minimum 2-year follow-up, was performed. Results. There were 126 patients in the P group and 124 in the R group. Mean age at surgery (P = 51.2 vs. R = 51.6 years, P = 0.79), length of follow-up (P = 3.6 vs. R = 3.6 years, P = 0.94), comorbidities (P = 0.43), and smoking status (P = 0.98) were similar between the 2 groups. Body mass index (P = 25.5 vs. R = 27.4 kg/m2, P = 0.01), number of final instrumented levels (P = 10.5 vs. R 12.1 levels, P = 0.00), fusion to the sacrum (P = 61.0% vs. R = 87.1%, P = 0.00), osteotomy (P = 14.3% vs. R = 54.9%, P = 0.00), length of surgery (P = 6.5 vs. R = 8.2 hours, P = 0.00), and estimated blood loss (P = 1072.1 vs. R = 1401.3 mL, P = 0.05) were different. Primary patients had significantly lower overall complications than revision patients (P = 45.2% vs. R = 58.2%, P = 0.042). Primary patients reported significantly higher preoperative and final clinical outcome measures in function, pain, and subscore SRS domains and ODI compared with revision patients (all P < 0.05). Patients older than 60 years of age, however, reported similar SRS and ODI scores between the 2 groups. The extent of surgical benefit patients received, that is, final minus preoperative score, was similar in all categories between the 2 groups. Conclusion. Adult patients undergoing primary scoliosis surgery had significantly lower overall complications compared with revision patients. Primary patients reported higher preoperative and final clinical outcome measures than revision patients, although this difference disappeared in older patients. The benefit of surgery was similar between the 2 groups.

Labral Disease Associated With Femoroacetabular Impingement

In this study, we compared the clinical results of arthroscopic partial labral resection to augmentation of this procedure with limited open osteochondroplasty for the treatment of symptomatic femoroacetabular impingement. Two consecutive cohorts were evaluated: (a) group I, arthroscopic treatment of labrum and articular cartilage, and (b) group II, hip arthroscopy augmented with limited osteochondroplasty of the femoral head-neck junction. Group I (23 hips) and group II (25 hips) patients had no difference in age, labral disease patterns, osteoarthritis grade, or chondromalacia. Mean follow-up was slightly longer in group I. The modified Harris Hip Score showed a trend toward higher values in group II. A 10-point improvement was more common in group II, and fewer group II patients required subsequent surgery. These preliminary data suggest that patients with cam femoroacetabular impingement may have improved clinical outcomes when the impingement deformity is corrected.