Nonoperative Treatment For Adult Spinal Deformity Research Articles

216. Contrary to popular belief, self-image in adult spinal deformity (ASD) is most correlated with physical and social function and mental health and minimally correlated with magnitude of spine deformity

BACKGROUND CONTEXT Self-image (SI) is the most negatively impacted health domain for ASD. SI also strongly correlates with ASD postoperative satisfaction. Surgeons often assume that negative SI is due to scoliosis and/or sagittal malalignment, however data from cancer patients indicates physical and social function is strongly associated with of self-image. Little data exists investigating SI in ASD. PURPOSE Evaluate the radiographic, demographic, and health related quality of life (HRQOL) variables most correlated with SI in operatively treated ASD patients. STUDY DESIGN/SETTING Regression analysis of radiographic, demographic and HRQOL domains most associated with baseline and postoperative improvements in SI for operatively treated ASD patients from a prospective multicenter database. PATIENT SAMPLE Surgically treated ASD patients enrolled into a prospective multicenter study of operative vs nonoperative treatment for ASD, minimum 2-year postoperative follow-up. OUTCOME MEASURES Numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36), Oswestry Disability Index (ODI), self-image domain of SRS-22r. METHODS Baseline SI was assessed for operatively treated patients enrolled into a prospective multicenter study of operative vs nonoperative treatment for ASD (inclusion criteria age >18 years, scoliosis > 20°, thoracic kyphosis >60°, and/or SVA>5cm). Patients were organized according to SRS-Schwab ASD deformity types, and SI was reevaluated at minimum 2-year follow up. Regression analysis was performed on patient demographic, radiographic, and HRQOL domains and correlated with SI and treatment satisfaction. RESULTS A total of 591 of 789 patients eligible for study were evaluated (mean follow-up 3.2 years). Regression analysis demonstrated baseline SI (mean=2.4, range 1-4.6) correlated significantly (p 0.05). SI correlated most with SRS-22r activity (R=0.57), SF-36 social function (R=0.56), ODI (R=-0.52), SRS-22r mental health (R=0.51), and SF-36 vitality (R=0.50) but weakly with back (R=-0.265) and leg pain (R=-0.170; p 0.05). At last follow up SI improved from preop (3.6, range 1.6-5), and correlated most with improvements in SRS-22r activity (R=0.53), ODI (R=-0.45), and SRS-22r mental health (R=0.45; p CONCLUSIONS Baseline SI and postoperative SI improvement for ASD correlated most with physical and social function and mental health. ASD treatment satisfaction at 2 years postoperative strongly correlated with SI. The correlations between SI and physical and social function were independent of pain and spine deformity magnitude as correlations between SI, pain scales, scoliosis and sagittal malalignment ranged from weak to nonsignificant. These findings are consistent with research surrounding SI and cancer patients. More research is needed regarding the psychology and physiology of SI for ASD to improve patient outcomes and treatment satisfaction. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Probability of severe frailty development among operative and nonoperative adult spinal deformity patients: an actuarial survivorship analysis over a 3-year period

BACKGROUNDLittle is known of how frailty, a dynamic measure of physiological age, progresses relative to age or disability status. Operative treatment of adult spinal deformity (ASD) may play a role in frailty remediation and maintenance. PURPOSECompare frailty status, severe frailty development, and factors influencing severe frailty development among ASD patients undergoing operative or nonoperative treatment. DESIGNRetrospective review with maximum follow-up of 3 years. SETTINGProspective, multicenter, ASD database. PARTICIPANTSPatients were consecutively enrolled from 13 participating centers. Inclusion criteria: ≥18 years undergoing either operative or nonoperative treatment for ASD, exclusion criteria: spinal deformity of neuromuscular etiology, presence of active infection, or malignancy. The mean age of the participants analyzed were 54.9 for the operative cohort and 55.0 for the nonoperative cohort. OUTCOMES MEASURESFrailty status, severe frailty development, and factors influencing severe frailty development. METHODSASD patients (coronal scoliosis ≥20°, sagittal vertical axis (SVA) ≥5 cm, Pelvic Tilt (PT) ≥25°, or thoracic kyphosis ≥60°) >18 y/o, with Base Line (BL) frailty scores were included. Frailty was scored from 0 to 1 (not frail: <0.3, frail 0.3–0.5, severe frailty >0.5) through the use of ASD-frailty index (FI) which has been validated using the International Spine Study Group (ISSG) ASD database, European Spine Study Group ASD database, and the Scoli-RISK-1 Patient Database. The ISSG is funded through research grants from DePuy Synthes and individual donations and supported the current work. Operative (Op) and Nonoperative (Non-Op) patients were propensity matched. T-tests compared frailty among treatment groups and BL, 1, 2, and ≥3 years. An actuarial Kaplan-Meier survivorship analysis with log-rank (Mantel-Cox) test, adjusting for patients lost to follow-up, determined probability of severe frailty development. Multivariate Cox Regressions gauged the effect of sagittal malalignment, patient and surgical details on severe frailty development. RESULTSThe analysis includes 472 patients (236 Op, 236 Non-Op) selected by propensity score matching from a cohort of 1,172. Demographics and comorbidities were similar between groups (p>.05). Op exhibited decreased frailty at all follow-up intervals compared with BL (BL: 0.22 vs Y1: 0.18; Y2: 0.16; Y3: 0.15, all p<.001). Non-Op displayed similar frailty from BL to 2Y follow up, and increased frailty at 3Y follow up (0.23 vs 0.25, p=.014). Compared with Non-Op, Op had lower frailty at 1Y (0.18 vs 0.24), 2Y (0.16 vs 0.23), and 3Y (0.15 vs 0.25; all p<.001). Cumulative probability of maintaining nonsevere frailty was (Op: 97.7%, Non-Op: 94.5%) at 1Y, (Op: 95.1%, Non-Op: 90.4%) at 2Y, and (Op: 95.1%, Non-Op: 89.1%) at ≥3Y, (p=.018). Among all patients, baseline depression (hazard ratio: 2.688[1.172–6.167], p=.020), Numeric Rating Scale (NRS) back pain scores (HR: 1.247[1.012–1.537], p=.039), and nonoperative treatment (HR: 2.785[1.167–6.659], p=.021) predicted severe frailty development with having a HR>1.0 and p value<.05. Among operative patients, 6-week postoperative residual SVA malalignment (SRS-Schwab SVA+modifier) (HR: 15.034[1.922–116.940], p=.010) predicted severe frailty development indicated by having a HR>1.0 and p value <.05. CONCLUSIONSNon-Op patients were more likely to develop severe frailty, and at a quicker rate. Baseline depression, increased NRS back pain scores, nonoperative treatment, and postoperative sagittal malalignment at 6-week follow-up significantly predicted severe frailty development. Operative intervention and postoperative sagittal balance appear to play significant roles in frailty remediation and maintenance in ASD patients. Frailty is one factor, in a multifactorial conservation, that may be considered when determining operative or nonoperative values for ASD patients. Operating before the onset of severe frailty, may result in a lower complication risk and better long-term clinical outcomes.

Outcomes of Operative and Nonoperative Treatment in Patients with Adult Spinal Deformity with a Minimum 2-Year Follow-Up: A Meta-Analysis

More recent studies have focused on clinical outcomes of operative versus nonoperative treatment in patients with adult spinal deformity (ASD). However, scientific support for ASD surgery is weak. We compared outcomes of operative and nonoperative treatment of ASD with minimum 2-year follow-up in a meta-analysis. MEDLINE and EMBASE databases, from the earliest available date of indexing through May 10, 2018, were searched for studies evaluating outcomes of operative and nonoperative treatment of ASD. Two authors performed data extraction independently. Any discrepancies were resolved by consensus. Four comparative studies were identified. Postoperative back pain numeric rating scale and leg pain numeric rating scale scores were significantly lower with operative treatment compared with nonoperative treatment (P < 0.00001, weighted mean difference [WMD] =-2.76 [-3.45,-2.07] vs. P < 0.0001, WMD=-2.31 [-3.33,-1.28]). Postoperative Oswestry Disability Index and Scoliosis Research Society-22 questionnaire scores were significantly better with operative treatment compared with nonoperative treatment (P < 0.00001, WMD=-10.96 [-13.56,-8.36] vs. P < 0.00001, WMD= 0.68 [0.48, 0.87]). The complication rate of operative treatment was 17%-71.5%. Our meta-analysis showed that operative treatment has been demonstrated to significantly reduce disability and pain and to improve clinical outcomes compared with nonoperative treatment. Further large, multicenter, well-designed studies are necessary to substantiate our results.

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

High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed. To compare outcomes of operative and nonoperative treatment for ASD. 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. 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. 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. 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.

Significant Improvement in ASD with Operative vs Nonoperative Treatment

Evidence to date suggests that surgical treatment can improve pain and disability in adults with symptomatic spinal deformity. However, most previous studies were small, retrospective series without direct comparisons with nonoperative treatment approaches. The aim of this study, Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity (ASD): A Prospective, Multicenter Matched and Unmatched Cohort Assessment with Minimum Two-Year Follow-up was to compare minimum 2-year outcomes for operative and nonoperative treatment for ASD in a prospective population, using both matched and unmatched cohorts.