Mean Comparison Tests Research Articles

182. Impact of realignment schemas on rates of proximal junctional changes in adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Operative intervention for adult spinal deformity (ASD) is associated with high rates of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). Multiple attempts have been made to guide realignment for ASD corrective surgery, yet the predominance have been based on functional gains, which may or may not directly impact such junctional malcompensation. <h3>PURPOSE</h3> To assess impact of baseline patient deformity and surgical realignment on rates of PJK and PJF. <h3>STUDY DESIGN/SETTING</h3> Retrospective study of patients prospectively enrolled in a single center ASD database. <h3>PATIENT SAMPLE</h3> A total of 298 ASD patients. <h3>OUTCOME MEASURES</h3> Proximal junctional kyphosis (PJK); proximal junctional Failure (PJF). <h3>METHODS</h3> ASD patients with 2-year (2Y) data, UIV above L1 and LIV at S1 or pelvis were included. Those with evidence of PJK at 6-weeks postoperatively were excluded. Six-week radiographs were used to assess alignment by 5 published alignment systems: SRS-Schwab, GAP Score, age-adjusted (AA), Roussouly (Rous), and the newly published sagittal age-adjusted score (SAAS). To compare the impact of each alignment system on rates of PJK and PJF by level of baseline deformity, all radiographic measurements used to calculate SRS-Schwab, AA, Rous, GAP and SAAS were re-scaled from 0 to 100 using the min-max of the cohort for each respective angle. Normalized values were then summed to compute a composite "deformity score" for each patient. Patients were ranked by deformity score into 3 groups: mild, moderate, and severe. Means comparison tests were used to assess rates of PJK and PJF (defined as PJK with reoperation) by alignment system in the cohort and by deformity group. Multivariate logistic regressions controlling for covariates such as age, PJK prophylaxis, and osteoporosis were used to generate odds ratios (OR) and identify the alignment systems associated with lower odds of developing PJK and PJF. <h3>RESULTS</h3> A total of 298 patients met inclusion (62.5yrs, BMI: 27.5kg/m², CCI: 1.5, 76% F). Overall, 33.6% of the cohort developed PJK and 6.7% developed PJF. MVA of the cohort found those aligned to AA had a 55% lower odds of PJK (OR: 0.453, [0.283, 0.727], p=.001) and 60.4% lower odds of PJF (OR: 0.396, [0.169, 0.933], p=.034). Subanalysis of patients presenting with mild deformity scores (N=71) found none of the alignment systems reduced odds of PJK or PJF (all p>.05). Subanalysis of patients presenting with moderate deformity scores (N=108) found those meeting AA had 79% lower odds of PJK (OR: 0.210, [0.072, 0.615], p=.004), yet none of the alignment systems significantly reduced odds of PJF. In those severe deformity scores (N=119), meeting Schwab significantly reduced odds of PJK (OR: 0.492, [0.318, 0.761], p=.001). With regard to PJF, in those with severe deformity scores, alignment to Schwab (OR: 0.235, [0.104, 0.532], p=.001) and AA significantly reduced odds of PJF (OR: 0.352, [0.124, 0.994], p=.049). <h3>CONCLUSIONS</h3> This study aimed to assess impact of realignment to published systems on rates of PJK and PJF in surgical correction of adult spinal deformity. Overally, those meeting age-adjusted alignment had lowest rates of PJK and PJF. Morover, further analysis revealed that moderately and severely deformed patients beneit benefit from realignment to age adjusted criteria. However, none of the alignment systems were associated with lower odds of PJK or PJF in those presenting with mild deformity. This may indicate a certain level of PJK and PJF is not preventable by optimal realignment alone. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

79. Outcomes of a prone lateral single position approach to minimally invasive spine surgery

<h3>BACKGROUND CONTEXT</h3> The institution of single positioning throughout a combined approach to adult spinal surgery has many theorized benefits, including minimizing surgical measures like operative time and estimated blood loss that are highly correlated with higher rates of postoperative complications. However, prone lateral positioning has yet to be correlated to other important outcomes, including radiographic realignment and patient-reported outcomes. <h3>PURPOSE</h3> To investigate the surgical and postoperative outcomes of the prone lateral single-position approach to adult spinal deformity surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of a single-center database. <h3>PATIENT SAMPLE</h3> This study included 524 MIS patients. <h3>OUTCOME MEASURES</h3> Perioperative outcomes [EBL, LOS, op-time, lvls fused], intraoperative and postoperative complication rates, patient-reported outcomes. <h3>METHODS</h3> Operative spine fusion patients available baseline (BL) and up to two-year (2Y) data from a single-center database were isolated. Patients were stratified into two groups based on undergoing a prone lateral single-position combined approach, Prone Lateral (PL) vs MIS Non-Prone Lateral (NPL). Descriptive analyses and means comparison tests identified differences in baseline (BL) demographics, surgical details, radiographic parameters, rates of intraoperative and postoperative complications, and follow-up patient-reported outcomes up to 2 years. <h3>RESULTS</h3> A total of 233 patients (average age: 56.1±11.4 years, average BMI: 30.6±6.6 kg/m2, 54% of the cohort was male, CCI: 1.2±1.9) met inclusion criteria and underwent surgery (operative time: 320±152, EBL: 374±400 mL, levels fused: 2.4±1.2, LOS: 4.6±3.7 days). Regarding approach, 3 (1.3%) underwent lateral approach, 86 (38.6%) posterior, and 144 (60.1%) were combined. BL radiographic parameters: PI: 56.2±11.2, lumbar lordosis (LL): 53.0±12.9, PI-LL: 3.3±13.1, PT: 18.2±8.4, sacral slope (SS): 38.3±8.6. There were 103 same-day combined (lateral and posterior) procedures included in the cohort, with 22 of those being performed in the prone-lateral single position. When examining baseline demographics, the PL patients had mean age of 65.0±10.7, BMI of 28.3±4.7, CCI: 2.1±3.7, with 59% being male. Patients undergoing a prone lateral procedure had an average of 2.4±1.1 levels fused, EBL of 192±152 mLs, operative time of 200±103 minutes, while undergoing decompressions in 64% of procedures and osteotomies in 10%. Patients in the PL group were significantly older compared to non-PL patients (p <.001) with a lower BMI (p=.030) and higher CCI (p=.013). Patients undergoing PL procedures had lower EBL and operative time compared to non-PL patients (both p-value <.001), along with less osteotomies performed (10% vs. 43%, p=.002). Although, PL patients had a similar number of levels fused, they had a higher average LIV (L5 vs S1, p=.003) and UIV (L2 vs L3, p=.004) compared to the rest of the cohort. There were no radiographic differences preoperatively or postoperatively, although 50% of PL patients improved to aligned in PI-based sacral slope (GAP Relative Pelvic Version). PL patients suffered significantly less pulmonary (0% vs 4%, p=.019) and GI complications (0% vs 3%, p=.039), but endured higher rates of urinary retention (14% vs 5%, p=.032). This translated to a shorter length of stay (3.3 days vs 4.7, p=.004) for PL patients, with discharge to a rehab facility less often after leaving the hospital (0% vs 13%, p <.001). When examining patient-reported outcomes within one year after surgery, PL patients had greater improvement in NRS-Back (-6.0 vs -3.3, p=.031) and trending toward greater improvement in NRS-Leg (-4.6 vs -3.6, p=.132). <h3>CONCLUSIONS</h3> Patients undergoing prone lateral single-position procedures in this single-center database displayed less invasive procedures with similar degree of correction, endured lower rates of certain complications correlating to going home earlier and more often. These perioperative outcomes correlated to greater improvement of back pain following spinal corrective surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P96. A parameter fixed to poor outcomes: a detailed analysis of high Pelvic incidence in adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Pelvic incidence (PI) serves as the cornerstone for many deformity classifications and realignment schema to create a more individualized realignment target for each patient. Yet, previous literature has linked high PI to problematic outcomes following corrective surgery, including mechanical complications and hip pathologies. <h3>PURPOSE</h3> Investigate if patients with high pelvic incidence have increased risk for complications and poor clinical outcomes following ASD surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective. <h3>PATIENT SAMPLE</h3> A total of 689 ASD patients. <h3>OUTCOME MEASURES</h3> Clinical Outcomes (ODI, SF-36 PCS, MCS), mechanical failure, surgical details. <h3>METHODS</h3> ASD patients with 2-year (2Y) data included. Groups: PI >65° (HighPI) versus PI < 65° (NormPI). Means comparison tests assessed differences in demographics, surgical details and outcomes between groups. Multivariate analysis controlling for baseline age, frailty, baseline PI-LL, and history of prior fusion, analyzed complication rates and clinical improvement between groups. <h3>RESULTS</h3> Included: 445 ASD patients. There were 94 (21%) patients presented with a BL pelvic incidence greater than 65° (HighPI). HighPI patients were older (63 yrs), shorter, with higher BMI and frailty (all p<.05). HighPI were more likely to have had a prior fusion (OR: 1.9, [1.2-3.1]). HighPI were more likely to present with lower physical functioning scores, and severe pelvic compensation (OR: 5.5, [3.4-8.9]) and global deformity (OR: 3.5, [2.2-5.6]). During surgery, HighPI underwent more 3COs (OR: 1.8,[1.1-3.1]) and fusion to pelvis (OR: 2.1,[1.1-3.9]). Upon correction, adjusted analysis revealed HighPI were more likely to be undercorrected in each age-adjusted parameter compared to LowPI (OR: 4.8, [2.9-7.8]). Yet, HighPI patients were less likely to deteriorate within in-construct PI-based alignment (relative lordosis and lordosis distribution) (OR: 0.3,[0.1-0.9]). While not different at six weeks, HighPI were more likely to deteriorate in PI-based global alignment and pelvic compensation from six weeks to two years (OR: 3.2, [1.6-6.5]). This translated to a higher likelihood of developing a major or mechanical complication by 2Y (OR: 1.6, [1.04-2.6]) via adjusted analysis. <h3>CONCLUSIONS</h3> High pelvic incidence is associated with increased frailty, decreased physical functioning, and more severe lumbopelvic and global deformity upon presentation for adult spinal deformity correction. These patients are more often undercorrected by age-adjusted standards and deteriorate in out-of-construct alignment over time even when adequately corrected, leading to higher mechanical complications by two years. Despite our focus on PI-adjusted alignment, we have still not optimized treatment for the patient with high pelvic incidence. Further research should target which surgical techniques and strategies can achieve better results in this population. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

162. Predictors of a sustained clinical benefit following adult spinal deformity correction with a minimum 3-year follow-up

<h3>BACKGROUND CONTEXT</h3> Despite multiple reports showing favorable long-term functional outcomes following adult spinal deformity (ASD) correction, it is still unclear which patient factors may impact the sustainability of these outcomes. <h3>PURPOSE</h3> To assess the sustainability of functional gains following ASD correction and determine predictors for postoperative loss of patient functionality. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> A total of 689 ASD patients. <h3>OUTCOME MEASURES</h3> Sustained clinical benefit, Oswestry Disability Index (ODI), reoperation, mechanical failure, proximal junctional failure (PJF) <h3>METHODS</h3> ASD patients with baseline (BL) and three-year (3Y) follow-up data were considered for analysis. Only patients who met the definition of sustained clinical benefit (SCB) at one-year (1Y) were included: 1)Passias et al's threshold for ODI (ODI<31.3), 2) did not develop PJF, and 3) did not have a reoperation for a mechanical failure. Patient groups were created by those who met SCB at 3Y, and those who did not. SCB outcomes were also reported at five-years (5Y) postoperatively. Means comparison tests assessed differences in patient groups. Factors predicting SCB were identified using adjusted regression and conditional inference tree (CIT) analysis. <h3>RESULTS</h3> A total of 157 patients met inclusion criteria and had SCB at 1Y. Patient breakdown for SCB was 75.0% at 3Y. Gender (78% vs 81%), BMI (25.5 vs 26.4), levels fused (10.6 vs 10.5), operative time (345 vs 362 min), and surgical invasiveness were similar between groups, all P>.05. Following surgery, patient groups were similarly aligned to Lafage et al's age-adjusted PT, PI-LL, and SVA, all P>.05. Regression and CIT analysis adjusting for BL deformity determined that patients who met SCB at 3Y were 95.4% less likely to have an ASD-mFI score > 11 (.046[.005-.420], p=0.006), 73.1% less likely to be older than 55 years at DOS (.269[.091-.798], p=.018), 69.4% less likely to have a CCI score > 0(.306[.116-.811], p=.017), and 86.9% less likely to have a BL EQ5D score < .723 (.131[.029-.585], p=.008). Adjusted for patients without follow-up, sustained clinical benefit at 5Y was 57.9%. Predictors of SCB from 3Y to 5Y included age, CCI and EQ5D, all P < .05. <h3>CONCLUSIONS</h3> Sustained clinical benefit was maintainable for 75.0% of the operative ASD cohort at 3Y. Similarly, a 57.9% maintenance rate of sustained clinical benefit at 5Y reflects the longevity of ASD correction. Independent predictors of sustained clinical benefit included age, frailty, comorbidities and the patient health state. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P100. Are we focused on the wrong early postoperative quality metrics? Optimal realignment outweighs perioperative risk in adult spinal deformity surgery

BACKGROUND CONTEXT While reimbursement is centered on 90-day outcomes, some patients persevere through these short-term, transient complications and manage to still achieve optimal, long-term outcomes. PURPOSE Assess whether achieving optimal alignment suffering similar perioperative complications compared to suboptimally-aligned peers are inhibited from reaching long-term clinical success and better cost-utility. STUDY DESIGN/SETTING Retrospective cohort study of a prospective adult spinal deformity (ASD) database. PATIENT SAMPLE A total of 1,541 patients. OUTCOME MEASURES Cost-per-QALY, radiographic realignment, clinical outcomes. METHODS Operative ASD pts with 2Y data were included. Optimal radiographic outcome was defined by SRS-Schwab low deformity in PI-LL, matched in T1PA and being aligned in PI-based PT at 6 weeks. After stratifying pts based on meeting optimal outcome, multivariate analysis controlling for baseline demographics was used to determine significance for complications and hospital-acquired conditions (HACs; DVT/PE, UTI, deep/superficial infection). Calculated Cost per QALY for each time point by 2Y. RESULTS There were 917 ASD pts included. Regarding approach, 69% posterior approach, 31% combined. Groups: 131 were "optimal" (O) and 786 were "not optimal" (NO). Means comparison tests revealed significant differences in age, BMI, but not gender or frailty. The NO group had fewer osteotomies and a lower Invasiveness Index. Analysis of perioperative complications showed that the O group suffered equivocal perioperative complications (58.0% vs 52.2% in the NO group; p=.173) and rates of HACs (9.0% vs. 8.9%, p=.810). Analysis of long-term complications showed that patients in the NO group suffered more major neurological (p=.015) and major mechanical complications (p=.025), and more reoperations (28.7% vs 19.9%; p=.037). When controlling for baseline deformity, age, BMI and frailty, Optimal Outcome patients more often met Best Clinical Outcome (21.5% vs. 11.7%, p=.002). Cost-utility adjusted analysis with determined no difference in the two groups by 6 weeks and 6 months. However, the O group generated significantly better cost-utility by one year, which maintained lower Costs per QALY (p=.005) at two years in favor of the O group. CONCLUSIONS Despite incurring equivocal perioperative complications, patients who met our optimal outcome criteria experienced significantly less mechanical complications and reoperations by 2 years, leading to a better long-term cost-utility overall. Accordingly, a higher, transient perioperative complication profile should not preclude surgical correction and future policy efforts should place more consideration on the long-term for outcome measures in adult spinal deformity surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. While reimbursement is centered on 90-day outcomes, some patients persevere through these short-term, transient complications and manage to still achieve optimal, long-term outcomes. Assess whether achieving optimal alignment suffering similar perioperative complications compared to suboptimally-aligned peers are inhibited from reaching long-term clinical success and better cost-utility. Retrospective cohort study of a prospective adult spinal deformity (ASD) database. A total of 1,541 patients. Cost-per-QALY, radiographic realignment, clinical outcomes. Operative ASD pts with 2Y data were included. Optimal radiographic outcome was defined by SRS-Schwab low deformity in PI-LL, matched in T1PA and being aligned in PI-based PT at 6 weeks. After stratifying pts based on meeting optimal outcome, multivariate analysis controlling for baseline demographics was used to determine significance for complications and hospital-acquired conditions (HACs; DVT/PE, UTI, deep/superficial infection). Calculated Cost per QALY for each time point by 2Y. There were 917 ASD pts included. Regarding approach, 69% posterior approach, 31% combined. Groups: 131 were "optimal" (O) and 786 were "not optimal" (NO). Means comparison tests revealed significant differences in age, BMI, but not gender or frailty. The NO group had fewer osteotomies and a lower Invasiveness Index. Analysis of perioperative complications showed that the O group suffered equivocal perioperative complications (58.0% vs 52.2% in the NO group; p=.173) and rates of HACs (9.0% vs. 8.9%, p=.810). Analysis of long-term complications showed that patients in the NO group suffered more major neurological (p=.015) and major mechanical complications (p=.025), and more reoperations (28.7% vs 19.9%; p=.037). When controlling for baseline deformity, age, BMI and frailty, Optimal Outcome patients more often met Best Clinical Outcome (21.5% vs. 11.7%, p=.002). Cost-utility adjusted analysis with determined no difference in the two groups by 6 weeks and 6 months. However, the O group generated significantly better cost-utility by one year, which maintained lower Costs per QALY (p=.005) at two years in favor of the O group. Despite incurring equivocal perioperative complications, patients who met our optimal outcome criteria experienced significantly less mechanical complications and reoperations by 2 years, leading to a better long-term cost-utility overall. Accordingly, a higher, transient perioperative complication profile should not preclude surgical correction and future policy efforts should place more consideration on the long-term for outcome measures in adult spinal deformity surgery.

Natural History of Adult Spinal Deformity: How Do Patients with Less Than Optimal Surgical Outcomes Fare Relative to Non-Operative Counterparts?

Introduction Management of adult spinal deformity (ASD) increasingly favors operative intervention, however complication rates remain high. This study compares health-related-quality-of-life (HRQL) metrics of patients with suboptimal surgical outcomes to non-operative management, which approximates the natural history of ASD. Methods This is a retrospective analsis of operative and non-operative patients(≥18yo) from a single-center ASD database. Patients with baseline and 2-year follow-up were included. For non-operative patients, decision to forego surgery was made by the patient. Operative patients were selected for “suboptimal outcomes,” defined as any reoperation, major complication, or ≥2 severe SRS-Schwab modifiers at 2-years. Suboptimal operative(SOp) vs. natural history (NH) groups were propensity score matched (PSM) by age, deformity, Oswestry-Disability-Index (ODI), and comorbidities. Means comparison tests assess differences in improvement and rates of achieving minimal clinically important difference (MCID) in ODI and Scoliosis- Research-Society-22 (SRS-22). Results After PSM, 74 patients were included(37-SOp; 37-NH). SOp and NH groups were not significantly different in baseline demographics, HRQLs, or radiographic deformity(Table 1). At 2Y, SOp patients had greater improvement in ODI and higher rates of reaching MCID, both p-values&lt;.001. SOp patients had significantly better SRS-22-Total, SRS-22-Pain and SRS-22-Satisfaction scores at 2Y, all p-values&lt;.001. Finally, significantly more SOp patients gained ≥1 MCID in SRS-Activity and SRS-Pain, both p-values&lt;.002. Conclusion Compared to the natural history of ASD, operative patients with suboptimal outcomes still experience significantly greater improvement in HRQLs. Such divergent outcomes at 2Y, highlight the stagnation and deterioration associated with the disease process. Spine surgeons should consider the outcomes associated with the natural history of ASD when weighing risks and benefits of operative intervention.

164. Critical analysis of the presence of spinal cord dysfunction among adult cervical deformity at presentation and the effect of corrective surgery on resolution of symptoms

BACKGROUND CONTEXT Patients with both adult degenerative and myelopathic conditions of the upper spine, along with progressive symptoms, are often eligible for corrective surgery. The impact and prevalence of myelopathy due to spinal cord dysfunction in adult cervical deformity (CD) surgery remains understudied. PURPOSE To investigate the rates of neurological deficits and improvements among patients with severe deformity and by morphotype breakdown. STUDY DESIGN/SETTING Retrospective cohort study of a prospective adult cervical deformity (CD) database. PATIENT SAMPLE A total of 280 CD patients. OUTCOME MEASURES Neurological symptoms, neurological improvements. METHODS CD patients 18 years old with complete baseline (BL) and 3M postoperative HRQL and radiographic data. Patient baseline and post-operative myelopathy signs and symptoms were assessed. Mild myelopathy was defined as mJOA 15-17, Moderate 12-14, and Severe <12. Means comparison tests assessed baseline clinical, radiographic, and demographic factors between patients with severe and mild/moderate myelopathy. RESULTS A total of 170 CD patients met inclusion criteria. Of these, 24% had mild myelopathy, 39% had moderate myelopathy, and 30% had severe myelopathy. Patients with severe myelopathy had a greater degree of frailty (.2 vs .26), greater comorbidity burden (CCI: 1.2 vs .7), disability (NDI: 63 vs 54) with a substantially lower mJOA (9.8 vs 14.5, all p< .05). Severe myelopathy patients also had a longer LOS (6.6 vs 4.8 days) and developed DJF at greater rates (14% vs 5%). Overall, 113 (67%) patients had BL neuro symptoms: 10% bladder incontinence, 6% bowel incontinence, 27% gait instability, 37% hand clumsiness, 60% hand numbness, 7% Lhermitte's sign, 45% bilateral paresthesia and 56% weakness. After surgical intervention, 39% improved in degree of myelopathy. Postoperative myelopathy was 13% mild, 14% moderate and 10% severe. Patients with severe BL myelopathy showed improvements in NDI (63 to 51), mJOA (9.8 to 12.5) and NSR Neck (7.8 to 5.2, all p < .001). However, compared to mild/moderate myelopathy patients, severely myelopathic patients maintained a greater postoperative disability (51 vs 41), and worse degree of myelopathy (12.5 vs 14.3), when compared to mild/moderate patients p<.05. CONCLUSIONS Surgical correction shows substantial efficacy in resolution of myelopathy and improvements in functional status among adult cervical deformity patients. Severely myelopathic patients present with a greater degree of morbidity, frailty and disability, and despite improving post-operatively, maintained a substantially greater disability and neurological impairment postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Patients with both adult degenerative and myelopathic conditions of the upper spine, along with progressive symptoms, are often eligible for corrective surgery. The impact and prevalence of myelopathy due to spinal cord dysfunction in adult cervical deformity (CD) surgery remains understudied. To investigate the rates of neurological deficits and improvements among patients with severe deformity and by morphotype breakdown. Retrospective cohort study of a prospective adult cervical deformity (CD) database. A total of 280 CD patients. Neurological symptoms, neurological improvements. CD patients 18 years old with complete baseline (BL) and 3M postoperative HRQL and radiographic data. Patient baseline and post-operative myelopathy signs and symptoms were assessed. Mild myelopathy was defined as mJOA 15-17, Moderate 12-14, and Severe <12. Means comparison tests assessed baseline clinical, radiographic, and demographic factors between patients with severe and mild/moderate myelopathy. A total of 170 CD patients met inclusion criteria. Of these, 24% had mild myelopathy, 39% had moderate myelopathy, and 30% had severe myelopathy. Patients with severe myelopathy had a greater degree of frailty (.2 vs .26), greater comorbidity burden (CCI: 1.2 vs .7), disability (NDI: 63 vs 54) with a substantially lower mJOA (9.8 vs 14.5, all p< .05). Severe myelopathy patients also had a longer LOS (6.6 vs 4.8 days) and developed DJF at greater rates (14% vs 5%). Overall, 113 (67%) patients had BL neuro symptoms: 10% bladder incontinence, 6% bowel incontinence, 27% gait instability, 37% hand clumsiness, 60% hand numbness, 7% Lhermitte's sign, 45% bilateral paresthesia and 56% weakness. After surgical intervention, 39% improved in degree of myelopathy. Postoperative myelopathy was 13% mild, 14% moderate and 10% severe. Patients with severe BL myelopathy showed improvements in NDI (63 to 51), mJOA (9.8 to 12.5) and NSR Neck (7.8 to 5.2, all p < .001). However, compared to mild/moderate myelopathy patients, severely myelopathic patients maintained a greater postoperative disability (51 vs 41), and worse degree of myelopathy (12.5 vs 14.3), when compared to mild/moderate patients p<.05. Surgical correction shows substantial efficacy in resolution of myelopathy and improvements in functional status among adult cervical deformity patients. Severely myelopathic patients present with a greater degree of morbidity, frailty and disability, and despite improving post-operatively, maintained a substantially greater disability and neurological impairment postoperatively.

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

<h3>BACKGROUND CONTEXT</h3> Surgical correction of adult spinal deformity (ASD) has been associated with superior alignment and functional outcomes. However, postoperative complication rates remain relatively high. The extent to which potentially modifiable patient-related factors can influence complication rates in adult spinal deformity patients has not been effectively evaluated. <h3>PURPOSE</h3> Evaluate the association between modifiable patient-related factors on complications following ASD corrective surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective. <h3>PATIENT SAMPLE</h3> A total of 689 ASD patients. <h3>OUTCOME MEASURES</h3> Complication and reoperation rates. <h3>METHODS</h3> ASD patients with 2-year (2Y) data were included. Complication groups were defined as follows: 1) any complication; 2) major; 3) medical (cardiac event, ileus, etc.); surgical (site infection, wound dehiscence, etc.); 5) major mechanical (implant failure, rod fracture); 6) major radiographic (PJF [proximal junctional failure], pseudarthrosis, adjacent segment disease); and 7) reoperation. Modifiable risk factors included current smoker, obesity (BMI >30kg/m²), osteoporosis, alcohol use, depression (BL SF-36 MCS <35, perMatcham), psychiatric diagnosis and hypertension. Patients were stratified by BL deformity severity in T1PA (LowDef/HighDef) and age above or below 65 (Young/Older). Means comparison tests assessed prevalence of modifiable risk factors present in those developing specified complications. Binary logistic regression analysis was used to adjust for confounders. <h3>RESULTS</h3> A total of 480 ASD patients met inclusion criteria (age 59±15 yrs, 77%F, BMI 27±5 kg/m², CCI: 1.7±1.7). By 2Y, comp rates: 72% one complication, 28% major, 21% medical, 27% surgical, 11% major radiographic, and 8% had a major mechanical complication. A total of 106 patients (22%) required reoperation. Overall, 318 patients (66%) had at least one of the preoperative risk factors. Age-Deformity Groups: 32% Young LowDef, 19% Young HighDef, 18% Older LowDef, 31% Older HighDef. Within Young LowDef, patients with osteoporosis were more likely to suffer either a major mechanical or radiographic comp (both OR >6, p<.05), although this trend was not seen in the overall cohort. Young HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR: 2.8, [1.04-8.6]; p=.045), while patients with depression or a psychiatric diagnosis suffered major radiographic comps and underwent reoperation more often. Older patients with HighDef developed significantly more complications when diagnosed with depression, including major radiographic comps (23% vs 8%, OR: 3.5, [1.1-10.6]; p=.03). Overall, when controlling for baseline deformity, frailty, and osteoporosis, a diagnosis of depression proved to be a significant risk factor for development of major radiographic complications (OR: 2.4, [1.3-4.5]; p=.005). <h3>CONCLUSIONS</h3> Certain modifiable patient-related factors, especially mental health status, are associated with increased risk for complications following spinal deformity surgery. Therefore, with consideration to clinical presentation, elaborate on the utility in medical intervention prior to undergoing spinal deformity corrective surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

161. Expectations of clinical improvement following corrective surgery for adult cervical deformity based on functional disability at presentation

161. Expectations of clinical improvement following corrective surgery for adult cervical deformity based on functional disability at presentation

Re-thinking the online distance instruction based on students' feedback.

During the covid-19 pandemic, schools at all levels were often closed and online distance instruction (ODI) was applied. The main objective of this research was to discover the main didactic features of online distance instruction; and based on the collected data to define didactic recommendations towards improving the quality of the process. Five hypotheses were set that evaluated students’ opinions in the areas of teachers’ support for learners within ODI, types of sources exploited within ODI, means used for practising and fixing new knowledge within ODI, assessment of learners’ performance within ODI, and students’ feedback on ODI. In total, 272 respondents from upper secondary and higher education institutions participated in the research. Each respondent described the process of online distance instruction in two courses they selected of 64: (1) in a course that they appreciated, liked, enjoyed, and considered efficient from the point of view of their learning; (2) in a course that caused them discomfort in learning, as it was conducted in a way that did not suit them, and their learning did not bring the expected learning outcomes. Data were collected via a questionnaire; Chí-square test, adjusted residuals, and t test for comparison of means were calculated. Before the research started, teachers were trained in online distance instruction. Therefore, we expected that they will be competent in designing online distance courses and the courses will follow didactic principles. The results discovered significant differences in the frequency of occurrence of observed features in courses that received positive feedback compared to those having negative evaluation. However, some exceptions were detected.

Carbon Sequestration in Fine Aroma Cocoa Agroforestry Systems in Amazonas, Peru

One way to mitigate climate change is by reducing atmospheric CO2 levels with the establishment of agroforestry systems (AFSs) that can capture and store atmospheric CO2. This study therefore estimated the carbon sequestration in two components, aboveground (cocoa trees, other tree species, and leaf litter) and soil, in 15 fine aroma cocoa AFSs in Amazonas, Peru. These cocoa AFSs had a minimum area of 1.5 ha and were distributed into three age groups (each group consisted of five systems or farms): young cocoa trees between 8 and 15 years old, middle-aged cocoa trees between 16 and 29 years old, and adult cocoa trees between 30 and more than 40 years old. Generalized linear mixed model (GLMM) analysis followed by Fisher’s LSD mean comparison test (p &gt; 0.05) determined the significant level of total aboveground biomass and total carbon content in the AFSs’ components. The present findings confirm that Theobroma cacao, Mussa sp., Cordia sp., and Persea sp. were the most common species in all AFSs. Clearly, biomass and carbon content in Theobroma cacao and Cordia sp. increased slightly with age, while fruit species Mussa sp. and Persea sp. decreased with age. The total aboveground carbon stock in young cocoa tree systems (13.64 Mg ha−1) was lower than in middle-aged cocoa systems (20.50 Mg ha−1) and adult cocoa systems (24.86 Mg ha−1); nevertheless, no significant differences were found for any of the age ranges. On the other hand, carbon stocks in soil (up to 30 cm depth) in the AFSs ranged from 119.96 Mg ha−1 to 131.96 Mg ha−1. Meanwhile, the total carbon stored by aboveground and soil components in adults cocoa systems (156.81 Mg ha−1) was higher compared to middle-aged cocoa systems (140.60 Mg ha−1) and young cocoa systems (133.59 Mg ha−1), although no statistically significant differences were found. Eventually, the CO2 sequestration for young cocoa systems was 490.28 Mg ha−1, and middle-aged and adult cocoa system recorded more than 500 Mg ha−1 of CO2. Furthermore, these data can further be used by national governments, local governments, and organisations of producers, particularly in accessing payments for environmental services, which may improve economic incomes and contribute to climate change mitigation by reserving biomass and sequestering C from these agroforestry cocoa systems.

GERMINACIÓN Y ASPECTOS MORFOLÓGICOS DE PLÁNTULAS DE Echinocactus platyacanthus Link &amp; Otto TRATADAS CON RAYOS GAMMA

&lt;p&gt;&lt;strong&gt;Background.&lt;/strong&gt; The sweet biznaga (&lt;em&gt;Echinocactus platyacanthus&lt;/em&gt;) is endemic to Mexico, whose seeds show low germination, viability, longevity, genetics, and latency; therefore, gamma irradiation is an alternative to stimulate the emergence and growth of seedlings, by causing variations in the chemical composition of DNA, which causes cytological, biochemical, physiological and morphological changes in plants. &lt;strong&gt;Objective.&lt;/strong&gt; The objective of the present investigation was to evaluate the effect of different doses of gamma &lt;sup&gt;60&lt;/sup&gt;Co radiation on seed germination and seedling vigor of &lt;em&gt;E. platyacanthus&lt;/em&gt;. &lt;strong&gt;Methodology.&lt;/strong&gt; &lt;em&gt;E. platyacanthus&lt;/em&gt; seeds were irradiated at 0, 50, 100, 150, 200, 250, 300, 350, 400, 450, 500 and 550 Gy of &lt;sup&gt;60&lt;/sup&gt;Co gamma rays, then they were sown in transparent plastic containers covered with filter paper and were distributed in a completely randomized design with four repetitions in a germination chamber, the percentage of germination and survival of seedlings in the container was recorded 30 days after sowing (das). The seedlings were transplanted at 30 das into black polyethylene bags with tezontle and established in a completely randomized design with 12 treatments and four replications, in a tunnel-type greenhouse. At 20 and 30 days after transplantation (dat) seedling vigor was measured based on height (cm), stem diameter (mm) and root length (mm) and at 20 dat survival was recorded (%) of seedling in the substrate. An analysis of variance and Tukey's test for comparison of means (p ≤ 0.05) were performed. &lt;strong&gt;Results.&lt;/strong&gt; Gamma irradiation stimulated seed germination from 10 to 29%. In seedlings, root height and length were modified with intermediate doses of gamma rays (100 to 200 Gy); but higher doses negatively affected these indicators. Survival of containerized M&lt;sub&gt;1&lt;/sub&gt; seedlings was up to 63% higher than the control, depending on the irradiation dose. &lt;strong&gt;Implications.&lt;/strong&gt; Irradiation with &lt;sup&gt;60&lt;/sup&gt;Co gamma rays improves seed germination, survival and vigor of &lt;em&gt;E. platyacanthus&lt;/em&gt; seedlings. &lt;strong&gt;Conclusions.&lt;/strong&gt; Irradiation with &lt;sup&gt;60&lt;/sup&gt;Co gamma rays stimulated seed germination and improved some characteristics of vigor in &lt;em&gt;E. platyacanthus&lt;/em&gt; seedlings, by modifying root height and length according to age. In addition, it increased the survival of containerized seedlings.&lt;/p&gt;

Enabling leaders of multispecialty teams via cross-training

BackgroundTeamwork across medical specialties improves patient outcomes. However, it also places an additional strain on team leaders, who must mediate between the medical specialties while at the same time belonging...

Efficacy of non-operative treatment of patients with knee arthrofibrosis using high-intensity home mechanical therapy: a retrospective review of 11,000+ patients

BackgroundRecovery from knee surgery or injury can be hindered by knee arthrofibrosis, which can lead to motion limitations, pain and delayed recovery. Surgery or prolonged physical therapy are often treatment options for arthrofibrosis, but they can result in increased costs and decreased quality of life. A treatment option that can regain lost motion without surgery would help minimize risks and costs for the patient. The purpose of this study was to determine treatment efficacy of high-intensity home mechanical stretch therapy in patients with knee arthrofibrosis.MethodsRecords were reviewed for 11,000+ patients who were prescribed a high-intensity stretch device to regain knee flexion. Initial and last recorded knee flexion and days between measurements were available for 9842 patients (Dataset 1). Dataset 2 was a subset of 966 patients from Dataset 1. These 966 patients had separate more rigorous measurements available from physical therapy notes (Dataset 3) in addition to data from the internal database (Dataset 2). Within and between dataset statistics were calculated using t tests for comparison of means and Cohen’s d for determination of effect size.ResultsAll dataset showed significant gains in flexion (p < 0.01). Mean initial flexion, last recorded flexion and flexion gain were 79.5°, 108.4°, and 29.9°, respectively in Dataset 1. Differences between Datasets 2 and 3 had small effect sizes (Cohen’s d < 0.17). The were no significant differences when comparing workers’ compensation and non-workers’ compensation patients. The average last recorded flexion for all datasets was above the level required to perform activities of daily living. Motion gains were recorded in under 60 days from device delivery.ConclusionsHigh-intensity home mechanical stretch therapy was effective in restoring knee flexion, generally in 2 months or less, and in avoiding additional surgery in severe motion loss patients regardless of sex, age, or workers’ compensation status. We believe high-intensity stretching should be considered in any patient who is at risk for a secondary motion loss surgery, because in over 90% of these patients, the complications and costs associated with surgery can be avoided.

Perception of Muslim Students on Learning Management System

Learning Management System (LMS) is essential for knowledge acquisition and learning management in the digital era. Users are regarded as significant stakeholders who impact the system's longevity, and their attitudes regarding the system are considered. This study compares student satisfaction levels across Moodle and Google Classroom learning platforms. This study employs a quantitative approach. A survey questionnaire was specially designed to collect data from the sample. The sample of 322 students was divided into two groups: 161 using Google Classroom and 161 using Moodle. The PIECES framework was used to quantify satisfaction. STATA's Z-test was used to examine the data in this study (mean-comparison test). According to the data, there was a difference in satisfaction with Moodle versus Google Classroom. Only one of the six criteria used to measure satisfaction shows that using Moodle with Google Classroom leads to the same level of satisfaction.

Genetic Groups of Fine-Aroma Native Cacao Based on Morphological and Sensory Descriptors in Northeast Peru.

The northeastern region of Peru is one of the centers of origin of cocoa due to the great diversity of this cultivar. The objective of this study is, therefore, to search for different genetic groups of 146 ecotypes of fine-aroma native cacao from the northeastern region of Peru, based on the morphological descriptors of pods, seeds, sensory, yield, and sampling altitude. The data were analyzed using multivariate statistics; a cluster analysis was performed with the numerical and categorical variables, followed by a principal component analysis (PCA) and the DGC (Di Rienzo, Guzmán y Casanoves) mean comparison test for the numerical data. Contingency tables and the multiple correspondence analysis (MCA) were performed for the categorical data. We differentiated 5 genetic groups; helpfully, sensory characteristics of the flowers and pod, size and weight of the seeds, and pod index were in fact crucial in separating the groups. The ecotypes of the groups labeled as “Indes” and “Bagüinos” reported the best sensory characteristics with high floral and fruity notes and with a good yield expressed in pod index (13.88 and 11.88, respectively). Furthermore, these ecotypes are found at medium and high altitudes, above 500 m a.s.l., a factor that enables them to express their sensory and yield attributes. On the contrary, the ecotypes known as “Toribianos” and “Cajas” report the highest pod indices (20.77 and 16.78, respectively), resulting in low productivity. In the future, the variability of the ecotypes found will help establish genetic improvement programs that contribute to the development of cocoa farming in general.

OPTIMIZATION OF THE BIOMASS PRODUCTION FROM SPROUTS OF NEO-TROPICAL VEGETABLE SPECIES

Seed germination improves the nutritional quality of plant foods; since they increase the contentsand availability of essential nutrients and reduce the levels of antinutrients. A considerablenumber of species have been studied, but to date, there are few studies on vegetable species ofthe neo-tropics. The aim of this study was the evaluation and optimization of mineral nutrientsolutions [Adelusi-Oseni (AO), Ruakura (Ru), Maeda (M)] and their combinations with compostextracts (EC1, EC2, and EC3) obtained from three different solvents, on the development ofbiomass of four neo-tropical vegetable plants in Mexico: pumpkin (Cucurbita pepo L.), papalo[Porophyllum ruderale (Jacq.) Cass.], pipitza (Porophyllum linaria Cav.), and purslane (Portulacaoleracea L.). The hypothesis was that biomass production achieved with the nutrient solutionswould lead to the highest yield for each seed compared to the control. Germination was carriedout in Petri dishes with cotton pads as substrate, adding 5 mL of nutrient solution, along witha control grown with water, in a photoperiod of 12 h; continuing germination until completing96 h. San Cristóbal experimental design was applied to the nutrient mixtures with the greatestpositive impact on the production of biomass. An ANOVA was carried out with Tukey andDunnet means comparison tests. For pumpkin sprouts, solution EC3E2 managed to increaseseedling growth by 395.2 % in comparison to the control; EC2A displayed a greater elongationin comparison with the control of 84.7 % for papal sprouts; EC2A produced an increase of 15.8 %in pipitza. In purslane, EC2A produced an increase of 53.7 %. Nutrition with compost extractscan favour the production of biomass from sprouts.

Who Became Lonely during the COVID-19 Pandemic? An Investigation of the Socioeconomic Aspects of Loneliness in Japan.

The COVID-19 pandemic has impacted social and economic aspects of people’s lives in different ways, causing them to experience different levels of loneliness. This study examines the extent of loneliness among men and women of various ages in Japan during the pandemic and attempts to determine the underlying causes. We used data from Hiroshima University’s nationwide survey conducted before and during the pandemic in Japan. The sample consists of 3755 participants, of which 67% are men and 33% are women with an average age of 51 years (SD = 13.64). Using mean comparison tests and probit regression models, we show that loneliness is a common occurrence among the Japanese population and that a significant number of people became lonely for the first time during the pandemic. In general, loneliness was greater among younger respondents, but older people became lonelier during the pandemic. Simultaneously, we observed significant differences in loneliness across age and gender subsamples. Although depression and subjective health status contributed to loneliness, we found no single explanation for the loneliness experienced by people during the pandemic; rather, subsample analysis revealed that the causes of loneliness for each group differed. Nevertheless, we discovered that older people are at a higher risk of developing loneliness during the pandemic due to a variety of socioeconomic and behavioral factors. The findings of this study suggest that health authorities should not generalize cases of loneliness, but rather intervene individually in each group to avoid further complications.

EFFECT OF FARMING TECHNOLOGIES INTENSIFICATION ON WHEAT YIELD IN THE DRY STEPPE OF SIBERIA: AN ANALYSIS BASED ON THE METHOD OF PROPENSITY SCORE MATCHING

The study examines the effect of crop production technology intensification on wheat yield under drought conditions. The causal effect of fertilizers and herbicides usage was quantified based on a dataset of reports from 196 farms located in the Kulunda Steppe in Altai Krai. To quantify causal effects, the various methods were tested – Two Means Comparison tests and Linear regression. Due to the not experimental nature of the data, Propensity Score Matching was used to balance the sample based on the main indicative signs (covariates).&#x0D; We refined the effects of crop technologies intensification based on the balanced sample. The results showed that, according to all considered methods, intensification of agriculture even in the dry climatic conditions resulted in the expected growth of wheat yield. The average causal effect of intensive farming was +2.02 dt/ha. The results also showed that it is possible to obtain more correct estimates of causal effects based on balanced samples. Using simple approaches like Two Means Comparison methods lead to underestimation or overestimation. Finally, we highlighted some limitations and peculiarities of the Propensity Score Matching method. However, the Propensity Score Matching can be considered a good and prospective tool for developing digital services in agricultural analytics.

Disinfectants effectiveness in Tomato brown rugose fruit virus (ToBRFV) transmission in tobacco plants

&lt;p&gt;The importance of the &lt;em&gt;Tomato brown rugose fruit virus &lt;/em&gt;(ToBRFV) in the tomato and pepper crops in the world has created the need to investigate and test alternatives for its management. Preventive tactics are the best option to manage a viral disease, so the objective of this study was to evaluate the effectiveness of sodium hypochlorite, ethyl alcohol, quaternary ammonium salts, liquid soap and milk powder dissolved in water, applied by spraying and immersion of razor blades infested with the virus and inoculating mechanically on &lt;em&gt;Nicotiana rustica &lt;/em&gt;and &lt;em&gt;N. benthamiana &lt;/em&gt;leaves. A completely randomized design with five repetitions was used and the experimental unit was the area of a tobacco leaf delimited by a rectangle, and the response variable was the number of local lesions/ cm2 (LL/cm2). A non-parametric analysis and a Kruskal Wallis test for comparison of means were used to evaluate the treatments, and significative differences were found (Ji&amp;lt;.0001). Sodium hypochlorite (spraying) and the subsequent application of milk prevented the appearance of local lesions and the transmission of ToBRFV. While the worst treatments were ethyl alcohol (immersion) with an average of 12 LL/cm2, and quaternary ammonium salts (immersion) with 3.22 LL/cm2. The rest of the treatments significantly reduced the number of LL/cm2 (&amp;lt;1), but did not prevent the appearance of systemic symptoms in the inoculated plants.&lt;/p&gt;