When Not to Operate in Spinal Deformity: Identifying Subsets of Patients with Simultaneous Clinical Deterioration, Major Complications, and Reoperation.

Abstract

Retrospective review of a prospectively enrolled adult spinal deformity (ASD) database. To investigate what patient factors elevate the risk of sub-optimal outcomes after deformity correction. Currently, it is unknown what factors predict a poor outcome after adult spinal deformity surgery, which may require increased pre-operative consideration and counseling. Patients >18yrs undergoing surgery for ASD(scoliosis≥20°, SVA≥5cm, PT≥25°, or TK≥60°). An unsatisfactory outcome was defined by the following categories met at 2Y: (1) clinical: deteriorating in ODI at 2Y f/u (2) complications/reop: having a reoperation and major complication were deemed high risk for poor outcomes postoperatively (HR). Multivariate analyses assessed predictive factors of HR patients in adult spinal deformity patients. 633 ASD (59.9 years, 79%F, 27.7kg/m2, CCI: 1.74) were included. Baseline severe Schwab modifier incidence (++): 39.2% PI-LL, 28.8% SVA, 28.9% PT. 15.5% of patients deteriorated in ODI by 2 years, while 7.6% underwent a reoperation and had a major complication. This categorized 11 (1.7%) as HR. HR were more comorbid in terms of arthritis (73%) heart disease (36%) and kidney disease (18%), P<0.001. Surgically, HR had greater EBL (4431ccs), underwent more osteotomies (91%), specifically Ponte(36%) and Three Column Osteotomies(55%), which occurred more at L2(91%). HR underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all P<0.050. The multivariate regression determined a combination of a baseline DRAM score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score ≤3, cSVA >65mm, C2 slope >30.2°, CTPA >5.5° for an R2 value of 0.535 (P<0.001). When addressing adult spine deformities, poor outcomes tends to occur in severely comorbid patients with major baseline psychological distress scores, poor neurologic function, and concomitant cervical malalignment.