Treatment Of Adult Spinal Deformity Research Articles

210. Cost-utility analysis of bracing vs observation for adolescent idiopathic scoliosis

<h3>BACKGROUND CONTEXT</h3> High quality evidence has shown that bracing can prevent radiographic progression of spinal curvature in skeletally immature adolescent idiopathic scoliosis (AIS) patients with curves between 25° -45°. Despite popular use, the cost-utility of bracing has not been established. <h3>PURPOSE</h3> This study aimed to determine the cost-utility of bracing in AIS. <h3>STUDY DESIGN/SETTING</h3> Cost-utility analysis. <h3>PATIENT SAMPLE</h3> Hypothetical cohort of skeletally immature (Risser 1) AIS patient with a 35° right main thoracic curve. <h3>OUTCOME MEASURES</h3> Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. <h3>METHODS</h3> A decision-analysis model comparing bracing vs observation was developed for a hypothetical skeletally immature AIS patients. We estimated the probability, cost, and quality-adjusted life years (QALY) for each event based on comprehensive review of the AIS literature. Costs were adjusted for inflation based on Consumer Price Index and reported in terms of 2020 real dollars. QALYs were discounted at 3%. Incremental net monetary benefit (INMB) was calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates. <h3>RESULTS</h3> Our decision-analysis model revealed that bracing was the dominant treatment choice over observation at $50,000/QALY willingness to pay threshold. The net lifetime costs were $57,908 ± $5,443 with bracing and $79,079 ± $4,281 with observation. The net lifetime QALYs were 24.1 ± 1.9 with bracing and 23.8 ± 1.8 with observation. Bracing was favored in 99.6% of the simulations with a median INMB of $32,854 (95% CI, $13,695 to $45,689). The model was most sensitive to the impact of bracing vs observation on the probability of requiring surgical treatment as an adolescent or adult spinal deformity treatment later in life. <h3>CONCLUSIONS</h3> Cost-utility analysis demonstrates that bracing for AIS is dominant over observation, with a positive INMB. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Stratifying outcome based on the Oswestry Disability Index for operative treatment of adult spinal deformity on patients 60 years of age or older: a multicenter, multi-continental study on Prospective Evaluation of Elderly Deformity Surgery (PEEDS)

BACKGROUND CONTEXTPatients with adult spinal deformity suffer from disease related disability as measured by the Oswestry Disability Index (ODI) for which surgery can result in significant improvements. PURPOSEThe purpose of this study was to show the change in overall and individual components of the ODI in patients aged 60 years or older following multi-level spinal deformity surgery. STUDY DESIGNProspective, multicenter, multi-continental, observational longitudinal cohort study PATIENT SAMPLEPatients ≥60 years undergoing primary spinal fusion surgery of ≥5 levels for coronal, sagittal or combined deformity. OUTCOME MEASURESOswestry Disability Index (ODI) METHODS: Patients completed the ODI pre-operatively for baseline, then at 10 weeks, 12 months and 24 months post-operatively. ODI scores were grouped into deciles, and change was calculated with numerical score and improvement or worsening was further categorized from baseline as substantial (≥20%), marginal (≥10–<20%) or no change (within 10%). RESULTSTwo-hundred nineteen patients met inclusion criteria for the study. The median number of spinal levels fused was 9 [Q1=5.0, Q3=12.0]. Two-year mean (95% CI) ODI improvement was 19.3% (16.7%; 21.9%; p<.001) for all age groups, with mean scores improved from a baseline of 46.3% (44.1%; 48.4%) to 41.1% (38.5%; 43.6%) at 10 weeks (p<.001), 28.1% (25.6%; 30.6%) at 12 months (p<.001), and 27.0% (24.4%; 29.5%) at 24 months (p<.001). At 2 years, 45.5% of patients showed 20% or greater improvement in ODI, 23.7% improved between 10% and 20%, 26.3% reported no change (defined as±10% from baseline), 4.5% of patients reported a worsening between 10% to 20%, and none reported worsening greater than 20%. 59.0% of patients were severely disabled (ODI >40%) pre-operatively, which decreased to 20.2% at 2 years. Significant improvement was observed across all 10 ODI items at 12 and 24 months. The largest improvements were seen in pain, walking, standing, sex life, social life and traveling. CONCLUSIONSIn this prospective, multicenter, multi-continental study of patients 60 years or older undergoing multi-level spinal deformity surgery, almost 70% of patients reported significant improvements in ODI without taking into account surgical indications, techniques or complications. Clear data is presented demonstrating the particular change from baseline for each decile of pre-operative ODI score, for each sub-score, and for each age group.

The Comparison of Spinopelvic Parameters, Complications, and Clinical Outcomes After Spinal Fusion to S1 with or without Additional Sacropelvic Fixation for Adult Spinal Deformity: A Systematic Review and Meta-analysis.

Systematic review and meta-analysis. The purpose of the study was to compare the outcomes and after spinal fusion with or without iliac screw (IS) insertion for patients with adult spinal deformity (ASD). The number of patients undergoing multilevel spinal stabilization for the treatment of ASD is growing. However, the selection of spinopelvic fixation for ASD patients with long fusion is controversial. A comprehensive literature search was performed without time restriction according to the guidelines from the Cochrane Collaboration in May 2020 using PubMed, EMBASE, and the Cochrane Library. The comparison of the two types of fixation was evaluated by spinopelvic parameters, incidence rate of complications, rate of revision, and clinical outcomes at the last follow-up. The literature search identified 422 records, of which eight studies were included for meta-analysis with a total of 439 patients. All the included studies provided level III evidence. There was no significant difference in the sagittal vertical axis, pelvic incidence, the proximal junctional kyphosis rates, the pseudarthrosis rates, the revision rates, and the clinical outcomes at the last follow-up between those who receive sacrum fixation and sacropelvic fixation. Nevertheless, greater lumbar lordosis (LL) (weighted mean difference [WMD], 4.15; 95% confidence interval [CI] 2.46-5.84, P < 0.01), greater sacral slope (SS) (WMD, 2.32; 95% CI 1.21-3.43, P < 0.01), and lower rate of the distal instrumentation instability (odds ratio, 0.25; 95% CI 0.10-0.61, P = 0.002) were observed in IS group between the comparison. The clinical outcomes in the IS group were similar to those in the non-IS group, but the application of the IS significantly restored LL, prevented decompensation, and reduced the occurrence of the distal instrumentation instability. Therefore, the IS may be a good choice for the operative treatment of ASD patients with sagittal malalignment and other risks of lumbosacral fracture, metal breakage, and screw pullout.Level of Evidence: 3.

Cost-effectiveness of Corrective Fusion Surgeries for Adult Spinal Deformities: A Comparison by Operative Method.

Retrospective cohort study. The aim of this study was to summarize the cost-effectiveness of surgical treatment for adult spinal deformity (ASD) according to the operative method over 2 years postoperatively. Extensive corrective fusion surgery for ASD requires numerous expensive implants, greatly contributing toward the national medical expenses. Previous national studies reported high complication rates in spinal surgeries using instrumentation. However, the cost-effectiveness of such procedures has not been scrutinized. In total, 173 ASD patients (151 women; mean age 69.1 years) who underwent corrective fusion between 2010 and 2017 were included. Cost-effectiveness was evaluated according to the cost of obtaining 1 quality-adjusted life year (QALY). Patients were divided into three groups: the "corrective fusion surgery using multiple Grade 2 osteotomy" (Grade-2) group, three-column osteotomy group (three-column), and lateral lumbar interbody fusion (LLIF) group. The average medical cost for the initial surgery was USD 72,240, and that during the 2 years after the initial surgery was USD 76,294. The medical expenses for the initial surgery and those over the 2 years were higher in the LLIF group. The cumulative improvement in QALY over the 2 years did not significantly differ among the groups (0.13, 0.15, and 0.18 in the Grade-2, three-column, and LLIF groups, respectively). Cost/QALY 2 years after the surgery was USD 509,370, 518,406, and 463,798 in the Grade-2, three-column, and LLIF groups, respectively. We summarized the medical costs and cost-effectiveness of three different surgical methods for ASD in patients with different backgrounds over 2 years postoperatively. The medical expense for the initial surgery was highest in the LLIF group, and the cumulative improvement in QALY over the 2 years tended to be higher in the LLIF group, but the difference was not significant; the overall cost-effectiveness was lowest in the LLIF group.Level of Evidence: 3.

Outcomes of Oblique Lateral Interbody Fusion for Adult Spinal Deformity: A Systematic Review and Meta-Analysis.

Study Design:A systematic review and meta-analysis.Objectives:To evaluate clinical and radiographic outcomes, and perioperative complications of oblique lateral interbody fusion (OLIF) for adult spinal deformity (ASD).Methods:We performed a systematic review and meta-analysis of related studies reporting outcomes of OLIF for ASD. The clinical outcomes were assessed by visual analogue scale (VAS) and Oswestry Disability Index (ODI). The radiographic parameters were evaluated by sagittal vertical axis (SVA), pelvic tilt (PT), sacral slope (SS), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence-lumbar lordosis (PI-LL), Cobb angle and fusion rate. A random effects model and 95% confidence intervals (CI) were performed to investigate the results.Results:A total of 16 studies involving 519 patients were included in the present study. The mean difference of VAS-back score, VAS-leg score and ODI score before and after surgery was 5.1, 5.0 and 32.3 respectively. The mean correction of LL was 20.6°, with an average of 6.9° per level and the mean correction of Cobb was 16.4°, with an average of 4.7° per level. The mean correction of SVA, PT, SS, TK and PI-LL was 59.3 mm, 11.7°, 6.9°, 9.4° and 20.6° respectively. The mean fusion rate was 94.1%. The incidence of intraoperative and postoperative complications was 4.9% and 29.6% respectively.Conclusions:OLIF is an effective and safe surgery method in the treatment of mild or moderate ASD and it has advantages in less intraoperative blood loss and lower perioperative complications.

The effect of upper instrumented vertebra level (T9 vs T10) on radiologic and functional outcomes in the surgical treatment of adult spinal deformity in osteoporotic patients over 60 years of age

The effect of upper instrumented vertebra level (T9 vs T10) on radiologic and functional outcomes in the surgical treatment of adult spinal deformity in osteoporotic patients over 60 years of age

Intraoperative image guidance for the surgical treatment of adult spinal deformity.

Operative management of adult spinal deformity (ASD) has been increasing in recent years secondary to an aging society. The advance of intraoperative image guidance, such as the development of navigation and robotics systems has contributed to the growth and safety of ASD surgery. Currently, intraoperative image guidance is mainly used for pedicle screw placement and the evaluation of alignment correction in ASD surgery. Though it is expected that the use of navigation and robotics would result in increasing pedicle screw accuracy as reported in other spine surgeries, there are no well-powered studies specifically focusing on ASD surgery. Currently, deformity correction relies heavily on preoperative planning, however, a few studies have shown the possibility that intraoperative image modalities may accurately predict postoperative spinopelvic parameters. Future developments of intraoperative image guidance are needed to overcome the remaining challenges in ASD surgery such as radiation exposure to patient and surgeon. More novel imaging modalities may result in evolution in ASD surgery. Overall there is a paucity of literature focusing on intraoperative image guidance in ASD surgery, therefore, further studies are warranted to assess the efficacy of intraoperative image guidance in ASD surgery. This narrative review sought to provide the current role and future perspectives of intraoperative image guidance focusing on ASD surgery.

Comparison of Outcomes Between Single-level Lateral Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion: A Meta-analysis and Systematic Review.

This is a meta-analysis and systematic review of the available literature. This study aims to compare the clinical and radiologic outcomes of single-level lateral lumbar interbody fusion (LLIF) with single-level transforaminal lumbar interbody fusion (TLIF). In the treatment of adult spinal deformity, LLIF allows interbody fusion while avoiding complications associated with an anterior or transforaminal approach, although the clinical outcomes of LLIF compared with other approaches have not been well established. We searched PubMed, Embase, and Scopus for 385 unique studies. On the basis of our exclusion criteria, 8 studies remained for our systematic review. Data were analyzed using Review Manager 5.3 using Mantel-Haenszel statistics and random effect models. This study identified self-reported Visual Analog Scale (VAS), Oswestry Disability Index, length of stay, blood loss, complication rate, and radiologic parameters (disk height, lumbar lordosis, segmental lordosis). Our meta-analysis showed that LLIF contributed to decreased blood loss [mean difference (MD)=-67.62 mL, 95% confidence interval (CI): -104 to -30.90, P<0.001], superior restoration of segmental lordosis (MD=1.91 degrees, 95% CI: 0.71-3.10, P=0.002), lumbar lordosis (MD=1.95 degrees, 95% CI: 0.15-3.74, P=0.03), and disk height (MD=2.18 mm, 95% CI: 1.18-3.17, P<0.001) when compared with TLIF. However, current data suggests no significant difference in clinical outcomes between LLIF and TLIF based on overall complication rates (P=0.22), length of hospital stay (P=0.65), postoperative Oswestry Disability Index (P=0.13), postoperative VAS Back Pain (P=0.47) and VAS Leg Pain (P=0.16). LLIF is an increasingly popular option for single-level anterior column reconstruction. When compared with single-level TLIF, single-level LLIF is associated with greater changes in lumbar lordosis and disk height. The single-level LLIF is a viable alternative to TLIF, demonstrating comparable clinical outcomes and better restoration of spinopelvic parameters. Level III.

Proximal Junctional Kyphosis and Proximal Junctional Failure in the Treatment for Adult Spinal Deformity: Definitions and Epidemiology

Proximal junctional failure (PJF) is considered to be one of the most serious complications after correction surgery with a long construct for adult spinal deformity. Proximal junctional kyphosis (PJK) was first defined as an angle between the lower endplate of the uppermost instrumented vertebra (UIV) and the upper endplate of UIV+2 of 10 degrees or greater, and at least 10 degrees greater than the preoperative measurement. Although PJK has been found to cause no significant clinical symptoms, PJF is regarded as a pathology associated with a fracture of UIV or UIV+1, posterior osseoligamentous disruption, or a pullout of instrumentation at the UIV, and may require revision surgery. The incidence of PJK or PJF is influenced by a variety of factors including the pathology of the deformity, surgical procedures and spinal construct, status of osteoporosis, prophylactic procedures, and the follow-up period. Therefore, the reported incidences of PJK vary widely, from 7.7% to 56%, whereas those of PJF vary widely, from 1.4% to 35%.

The feasibility of computer-assisted 3D navigation in multiple-level lateral lumbar interbody fusion in combination with posterior instrumentation for adult spinal deformity.

The lateral lumbar interbody fusion (LLIF) technique is used to treat many common spinal degenerative pathologies including kyphoscoliosis. The use of spinal navigation for LLIF has not been broadly adopted, especially in adult spinal deformity. The purpose of this study was to evaluate the feasibility as well as the intraoperative and navigation-related complications of computer-assisted 3D navigation (CaN) during multiple-level LLIF for spinal deformity. Retrospective analysis of clinical and operative characteristics was performed for all patients > 18 years of age who underwent multiple-level CaN LLIF combined with posterior instrumentation for adult spinal deformity at the University of Michigan between 2014 and 2020. Intraoperative CaN-related complications, LLIF approach-related postoperative complications, and medical postoperative complications were assessed. Fifty-nine patients were identified. The mean age was 66.3 years (range 42-83 years) and body mass index was 27.6 kg/m2 (range 18-43 kg/m2). The average coronal Cobb angle was 26.8° (range 3.6°-67.0°) and sagittal vertical axis was 6.3 cm (range -2.3 to 14.7 cm). The average number of LLIF and posterior instrumentation levels were 2.97 cages (range 2-5 cages) and 5.78 levels (range 3-14 levels), respectively. A total of 6 intraoperative complications related to the LLIF stage occurred in 5 patients. Three of these were CaN-related and occurred in 2 patients (3.4%), including 1 misplaced lateral interbody cage (0.6% of 175 total lateral cages placed) requiring intraoperative revision. No patient required a return to the operating room for a misplaced interbody cage. A total of 12 intraoperative complications related to the posterior stage occurred in 11 patients, with 5 being CaN-related and occurring in 4 patients (6.8%). Univariate and multivariate analyses revealed no statistically significant risk factors for intraoperative and CaN-related complications. Transient hip weakness and numbness were found to be in 20.3% and 22.0% of patients, respectively. At the 1-month follow-up, weakness was observed in 3.4% and numbness in 11.9% of patients. Use of CaN in multiple-level LLIF in the treatment of adult spinal deformity appears to be a safe and effective technique. The incidence of approach-related complications with CaN was 3.4% and cage placement accuracy was high.

182. Limited cost benefit of lateral interbody fusion (LIF) for adult spinal deformity (ASD) surgery in Japan

BACKGROUND CONTEXT Recently, multilevel lateral interbody fusion (LIF) has been used for the surgical treatment for adult spinal deformity (ASD). Despite the favorable clinical and radiographic outcomes in the previous literatures, the utility and cost effectiveness of LIF in conjunction with posterior spinal fusion (PSF) is still controversial. PURPOSE The purposes of this study were to compare the utility and cost effectiveness of multilevel LIF with PSF (L group) and PSF with TLIF (P group) in ASD surgery. STUDY DESIGN/SETTING Retrospective case series PATIENT SAMPLE Surgically treated 88 ASD patients (L group [n=39, mean age 69yrs] and P group [n=49, mean age 68yrs]) were identified retrospectively from multicenter database. OUTCOME MEASURES Demographic and radiographic data, health-related quality of life (HRQoL), and the direct hospitalization cost for the initial surgery and 2y total in hospitalization cost were analyzed. METHODS All patients were followed for minimum of 2yrs. The variables were collected from medical charts and retrospectively assessed. The student t-test, Mann-Whitney U-test and Chi-square test were used to statistically analyze the data. RESULTS Analyses of sagittal spinal alignment showed no significant difference between 2 groups at baseline and 2y post-op (P vs L: baseline C7SVA; 11cm vs 10 cm, p=0.71, PT; 33° vs 37°, p=0.10, PI-LL; 38° vs 37°, p=0.88, 2y post-op: C7SVA; 4cm vs 4 cm, p=0.74, PT; 23° vs 27°, p=0.06, PI-LL 6° vs 6°, p=0.97). Surgical time and blood loss were significantly higher in P group (P vs L: 268 vs 354 min, p CONCLUSIONS LIF with PSF is a similarly effective surgery for ASD when compared with the conventional PSF. However, due to the significantly higher cost, additional studies on the cost effectiveness of LIF in different ASD patient cohort are warranted. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

217. Outcomes of surgical treatment for patients with mild scoliosis and age appropriate sagittal alignment with minimum 2-year follow up

BACKGROUND CONTEXT Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. Despite these challenges it's well established that pts benefit from such treatment. However, the surgical outcomes for pts with mild scoliosis and age appropriate sagittal alignment have not been reported. PURPOSE To determine if patients (pts) with mild scoliosis and age appropriate sagittal alignment have favorable outcomes following surgical correction. STUDY DESIGN/SETTING Retrospective review of a prospective, multicenter ASD database. PATIENT SAMPLE ASD patients: operative pts age≥18, and all preoperartive pelvic tilt (PT), mismatch between pelvic incidence and lumbar lordosis (PI-LL), and C7 sagittal vertical axis (SVA) within established age adjusted parameters with minimum 2-year follow up. A subanalysis for pts with max coronal cobb angle 10-30° (mild scoli) was done. OUTCOME MEASURES Health-related quality of life (HRQOL) scores: Oswestry Disability Index (ODI), Short form-36(SF36), Scoliosis Research Society (SRS22), back/leg pain numerical rating scale (NRS) and minimum clinically important difference (MCID)/substantial clinical benefit (SCB). Radiographic values: max coronal cobb angle, coronal C7 plumb line, PT, PI-LL, thoracic kyphosis (TK), SVA. Demographic, frailty, surgical and complications data were collected. METHODS Two-year and baseline HRQOL/radiographic data were compared. RESULTS A total of 103 pts were included from 667 operative patients (89.3% female, avg age 59.8±13.1yrs). Of the 103 pts, 29 (28.2%) had max preop coronal cobb angle 10-30°. Two-year max coronal cobb angle and C7 coronal plumb were significantly improved compared to baseline (p CONCLUSIONS Pts with mild scoliosis and sagittal alignment within age appropriate parameters benefit from surgical correction at 2 years postop both radiographically and clinically including 81.5% meeting MCID for SRS pain despite having high complication rates. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

273. Economic burden of nonoperative treatment of adult spinal deformity

273. Economic burden of nonoperative treatment of adult spinal deformity

10. Pelvic nonresponders, postoperative cervical malalignment, and proximal junctional kyphosis following treatment of adult spinal deformity: influence of realignment strategies on occurrence

BACKGROUND CONTEXT For surgical adult spinal deformity (ASD) patients, determining optimal restoration of alignment and spinal shape is an active area of research. Complex corrective measures taken are in ASD. Incidence of specific alignment outcomes has yet to be investigated in each of the complex realignment ideals. PURPOSE Assess alignment outcomes (pelvic nonresponse [PNR], PJK, postop cervical deformity [CD]) following ASD-corrective surgery in the context of correction relative to various alignment schemas. STUDY DESIGN/SETTING Retrospective cohort study of prospective ASD database. PATIENT SAMPLE A total of 468 ASD patients. OUTCOME MEASURES PNR, PJK, postop CD. METHODS ASD patients with preop, 6-week postop (6W), and 2-year postop (2Y) radiographic data included. PNR: 10-year mismatch (undercorrection; unimproved) from a patient's age-adjusted PT at 6W and maintained at 2Y. Pelvic responder (PR): PT ±10 match age-adjusted goals. Patients were stratified by incremental additions of corrective alignment schemas: (a) improvement in Schwab SVA, (b) matching age-adjusted PI-LL, (c) match postop “ideal” and “theoretical” Roussouly, (d) improvement in proportionality spinal score at 6W. PNR, PJK, and CD development by 2Y were compared within groups, as well as simultaneous improvement/match of the suggested corrective measures (exclusively). In a subanalysis, patients were stratified by severity of baseline PT, low ( 30°) to determine which alignment schema is necessary to achieve less PNR, PJK and postop CD. RESULTS A total of 468 patients (56.3 yrs, 76.5% F; 25.6% PNR, 40.6% PR) met inclusion criteria. Rates of postop PJK (PNR:49.2% vs PR:59.5%) and CD (18.3% vs 25.8%) were significantly less in the PNR group, p 0.050). Undercorrected age-adjusted PI-LL presented with more PNR (60.1%), whereas overcorrected had increased PJK (68.2%), p CONCLUSIONS Following ASD corrective surgery, 25.6% of patients showed residual pelvic malalignment, qualifying as pelvic nonresponders. Use of complex realignment schemas (SRS-Schwab, age-adjusted, Roussouly shape, GAP) decreased rates of pelvic nonresponse, PJK and postop cervical deformity development. Severe (>30°) baseline pelvic tilt requires particular emphasis of proportionality in addition to other realignment ideals. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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.

The Impact of Surgical Correction of Adult Spine Deformity on Radiological Parameters and Its Correlation With Clinical Outcomes

To evaluate the correlations between changes in radiological parameters and clinical outcomes following adult spinal deformity (ASD) surgery. Radiological assessments are necessary for evaluation of deformity magnitude and choosing the appropriate surgical approach. Some studies have demonstrated the correlation between radiological parameters and pain and disability among patients. However, few studies have evaluated changes in both coronal and sagittal radiological parameters following the surgical treatment of ASD and its correlation with clinical outcomes. Radiological parameters include: pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), and PI minus LL (PI-LL), and Cobb’s angle and three clinical outcome measures include: visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 health survey (SF-36), were assessed at baseline and 6 and 12 months after surgery. A total of 95 patients were included. Mean VAS scores and ODI significantly improved from 7.09±2.1 and 61.07±13.6 to 2.64±1.6 and 31.8±16.1 respectively, after surgery (both P&lt;0.001). All items of the SF-36 survey, as well as all radiologic measures, improved significantly following surgery (both P&lt;0.001). We found a significant negative correlation between pre-operative SS and VAS scores (r= -0.307, P=0.002). Energy (r= -0.262, P=0.010) and social functioning (r= -0.248, P=0.015) scales of SF-36. PI-LL was positively associated with ODI (r=0.223, P=0.030) before surgery and energy scale (r= -0.262, P=0.010) of SF-36 after surgery. Surgical treatment of patients with ASD improves clinical outcomes, and in line with previous studies, restoration of sagittal alignment has a more important role in the enhancement of patients’ function and quality of life.

Three-Dimensional Printing for Preoperative Planning and Pedicle Screw Placement in Adult Spinal Deformity: A Systematic Review

Study Design:Systematic review.Objectives:This current systematic review seeks to identify current applications and surgical outcomes for 3-dimensional printing (3DP) in the treatment of adult spinal deformity.Methods:A comprehensive search of publications was conducted through literature databases using relevant keywords. Inclusion criteria consisted of original studies, studies with patients with adult spinal deformities, and studies focusing on the feasibility and/or utility of 3DP technologies in the planning or treatment of scoliosis and other spinal deformities. Exclusion criteria included studies with patients without adult spinal deformity, animal subjects, pediatric patients, reviews, and editorials.Results:Studies evaluating the effect of 3DP drill guide templates found higher screw placement accuracy in the 3DP cohort (96.9%), compared with non-3DP cohorts (81.5%, P < .001). Operative duration was significant decreased in 3DP cases (378 patients, 258 minutes) relative to non-3DP cases (301 patients,272 minutes, P < .05). The average deformity correction rate was 72.5% in 3DP cases (245 patients). There was no significant difference in perioperative blood loss between 3DP (924.6 mL, 252 patients) and non-3DP cases (935.6 mL, 177 patients, P = .058).Conclusions:Three-dimensional printing is currently used for presurgical planning, patient and trainee communication and education, pre- and intraoperative guides, and screw drill guides in the treatment of scoliosis and other adult spinal deformities. In adult spinal deformity, the usage of 3DP guides is associated with increased screw accuracy and favorable deformity correction outcomes; however, average costs and production lead time are highly variable between studies.

Surgical Outcomes of Multilevel Posterior Lumbar Interbody Fusion versus Lateral Lumbar Interbody Fusion for the Correction of Adult Spinal Deformity: A Comparative Clinical Study

Study DesignA retrospective case control study.PurposeThe purpose of this study was to compare the surgical outcomes of multilevel lateral lumbar interbody fusion (LIF) and multilevel posterior lumbar interbody fusion (PLIF) in the surgical treatment of adult spinal deformity (ASD) and to evaluate the sagittal plane correction by combining LIF with posterior-column osteotomy (PCO).Overview of LiteratureThe surgical outcomes between multilevel LIF and multilevel PLIF in ASD patients remain unclear.MethodsWe retrospectively reviewed 31 ASD patients who underwent multilevel LIF combined with PCO (LIF group, n=14) or multilevel PLIF (PLIF group, n=17) and with a minimum 2-year follow-up. In the comparison between LIF and PLIF groups, their mean age at surgery was 69.4 vs. 61.8 years while the mean follow-up period was 29.2 vs. 59.3 months. We evaluated the transition of pelvic incidence–lumbar lordosis (PI–LL) and disc angle (DA) in the LIF group, in fulcrum backward bending (FBB), after LIF and after posterior spinal fusion (PSF) with PCO. The spinopelvic radiographic parameters were compared between LIF and PLIF groups.ResultsCompared with the PLIF group, the LIF group had less blood loss and comparable surgical outcomes with respect to radiographic data, health-related quality of life scores and surgical time. In the LIF group, the mean DA and PI–LL were unchanged after LIF (DA, 5.8°; PI–LL, 15°) compared with the values using FBB (DA, 4.3°; PI–LL, 15°) and improved significantly after PSF with PCO (DA, 8.1°; PI–LL, 0°).ConclusionsIn the surgical treatment of ASD, multilevel LIF is less invasive than multilevel PLIF and combination of LIF and PCO would be necessary for optimal sagittal correction in patients with rigid deformity.

Decision Analysis in Quest of the Ideal Treatment in Adult Spinal Deformity Adjusted for Minimum Clinically Important Difference

Surgery appears to yield better results in adult spinal deformity treatment when fixed minimum clinically important difference values are used to define success. Our objective was to analyze utilities and improvement provided by surgical versus nonsurgical treatment at 2 years using Oswestry Disability Index with treatment-specific minimum clinically important difference values. From a multicenter database including 1452 patients, 698 with 2 years of follow-up were analyzed. Mean age of patients was 50.95 ± 19.44 years; 580 patients were women, and 118 were men. The surgical group comprised 369 patients, and the nonsurgical group comprised 329 patients. The surgical group was subcategorized into no complications (192 patients), minor complications (97 patients) and major complications (80 patients) groups to analyze the effect of complications on results. Minimum clinically important differences using Oswestry Disability Index were 14.31, 14.96, and 2.48 for overall, surgical, and nonsurgical groups. Utilities were calculated by visual analog scale mapping. Surgical treatment provided higher utility (0.583) than nonsurgical treatment (0.549) that was sensitive to complications, being 0.634, 0.564, and 0.497 in no, minor, and major complications. Probabilities of improvement, unchanged, and deterioration were 38.3%, 39.2%, and 22.5% for surgical treatment and 39.4%, 10.5%, and 50.1% for nonsurgical treatment. Improvement in the surgical group was also sensitive to complications with rates of 40.1%, 39.3%, and 33.3%. Our results suggest that surgical treatment has less disease burden and less chance of deterioration, but equal chances for improvement at 2 years of follow-up. As it appears to be a better modality in the absence of complications, future efforts need be directed to decreasing the complication rates.

Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study.

Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD. The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection. Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence-lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection. Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.