Sagittal spino-pelvic alignment failures following three column thoracic osteotomy for adult spinal deformity

Purpose

Three column thoracic osteotomy (TCTO) is effective to correct rigid thoracic deformities, however, reasons for residual postoperative spinal deformity are poorly defined. Our objective was to evaluate risk factors for poor spino-pelvic alignment (SPA) following TCTO for adult spinal deformity (ASD).

Methods

Multicenter, retrospective radiographic analysis of ASD patients treated with TCTO. Radiographic measures included: correction at the osteotomy site, thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence (PI). Final SVA and PT were assessed to determine if ideal SPA (SVA < 4 cm, PT < 25°) was achieved. Differences between the ideal (IDEAL) and failed (FAIL) SPA groups were evaluated.

Results

A total of 41 consecutive ASD patients treated with TCTO were evaluated. TCTO significantly decreased TK, maximum coronal Cobb angle, SVA and PT (P < 0.05). Ideal SPA was achieved in 32 (78%) and failed in 9 (22%) patients. The IDEAL and FAIL groups had similar total fusion levels and similar focal, SVA and PT correction (P > 0.05). FAIL group had larger pre- and post-operative SVA, PT and PI and a smaller LL than IDEAL (P < 0.05).

Conclusions

Poor SPA occurred in 22% of TCTO patients despite similar operative procedures and deformity correction as patients in the IDEAL group. Greater pre-operative PT and SVA predicted failed post-operative SPA. Alternative or additional correction procedures should be considered when planning TCTO for patients with large sagittal global malalignment, otherwise patients are at risk for suboptimal correction and poor outcomes.     

Multilevel Schwab grade II osteotomies for sagittal plane correction in the management of adult spinal deformity

Background Context

Prior reports have compared posterior column osteotomies with pedicle subtraction osteotomies in terms of utility for correcting fixed sagittal imbalance in adolescent patients with deformity. No prior reports have described the use of multilevel Smith-Petersen Osteotomies (SPOs) alone for surgical correction in the adult spinal deformity (ASD) population.

Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from nonoperative to surgical treatment: initial steps to reduce ineffective ASD management

Background Context

Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings.

The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications

Background Context

In 2008, Mirza et al. designed and validated the first and only index capable of quantifying the complexity of spine surgery. However, this index is not fully applicable to adult spinal deformity (ASD) surgery as it does not include the surgical techniques most commonly used and most strongly associated with perioperative complications in patients with ASD.

Validity and responsiveness of PROMIS in adult spinal deformity: The need for a self-image domain

BACKGROUND CONTEXT

Validity and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) have been investigated in several orthopaedic subspecialties. PROMIS has shorter completion time and greater research flexibility for the heterogeneous adult spinal deformity (ASD) population versus the Oswestry Disability Index (ODI) and Scoliosis Research Society 22-item questionnaire (SRS-22r).

A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network – an international initiative

Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions.Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD.Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist.Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable.Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.     

Postoperative improvement in health-related quality of life: a national comparison of surgical treatment for focal (one- to two-level) lumbar spinal stenosis compared with total joint arthroplasty for osteoarthritis

Background context

The results of single-center studies have shown that surgical intervention for lumbar spinal stenosis yielded comparable health-related quality of life (HRQoL) improvement to total joint arthroplasty (TJA). Whether these results are generalizable to routine clinical practice in Canada is unknown.

Purpose

The primary purpose of this equivalence study was to compare the relative improvement in physical HRQoL after surgery for focal lumbar spinal stenosis (FLSS) compared with TJA for hip and knee osteoarthritis (OA) across six Canadian centers.

Study design/setting

A Canadian multicenter ambispective cohort study.

Patient sample

A cohort of 371 primary one- to two-level spinal decompression (n=214 with instrumented fusion) for FLSS (n=179 with degenerative lumbar spondylolisthesis [DLS]) was compared with a cohort of primary total hip (n=156) and knee (n=208) arthroplasty for OA.

Outcome measures

The primary outcome was the change in preoperative to 2-year postoperative 36-Item Short Form Health Survey Physical Component Summary (PCS) score as reflected by the number of patients reaching minimal clinically important difference (MCID) and substantial clinical benefit (SCB).

Methods

Univariate analyses were conducted to identify baseline differences and factors that were significantly related to outcomes at 2 years. Multivariable regression modeling was used as our primary analysis to compare outcomes between groups.

Results

The mean age (years) and percent females for the spine, hip, and knee groups were 63.3/58.5, 66.0/46.9, and 65.8/64.3, respectively. All three groups experienced significant improvement of baseline PCS (p<.001). Multivariate analyses, adjusting for baseline differences (age, gender, baseline Mental Component Summary score, baseline PCS), demonstrated no significant differences in PCS outcome between spinal surgery and arthroplasty (combined hip and knee cohorts) patients with an odds ratio of 0.80 (95% confidence interval [CI], 0.57–1.11; p=.17) and 0.79 (95% CI, 0.58–1.09; p=.15) for achieving MCID or SCB, respectively. In subgroup analysis, spine and knee outcomes were not significantly different, with hip arthroplasty superior to both (p<.0001).

Conclusions

Significant improvement in physical HRQoL after surgical treatment of FLSS (including DLS) is consistently achieved nationally. Our overall results demonstrate that a comparable number of patients can expect to achieve MCID and SCB 2 years after surgical intervention for FLSS and total knee arthroplasty.     

The Brisbane Burn Scar Impact Profile (child and young person version) for measuring health-related quality of life in children with burn scars: A longitudinal cohort study of reliability,validity and responsiveness

BackgroundClinical practice benefits from the measurement of health-related quality of life (HRQoL) to reflect the impact of the disease and treatments from the patient’s lived experience. The Brisbane Burn Scar Impact Profile (child and young person version, BBSIP^8?18), developed in 2013, is a self-report measure of burn scar-specific HRQoL. The purpose of the study was to test reliability, validity and responsiveness of this measure for an evaluative purpose.MethodsYoung people aged 8–18 years with burn scarring or at probable risk of burn scarring (defined as 14 days or longer to re-epithelialize) were included in a prospective, longitudinal cohort study. Data was collected at a paediatric burn centre at baseline (when ≥85% of the total body surface area re- epithelialized), then 1–2 weeks and 1-month post-baseline. Participants completed measures of HRQoL (BBSIP^8?18, Pediatric Quality of Life Inventory) and scar characteristics (Patient Observer Scar Assessment Scale) at each time-point.ResultsSixty-five participants completed the baseline testing. Forty-nine participants completed testing at 1–2 weeks post-baseline and thirty-two at 1-month post-baseline. Internal consistency of item groups ranged from Cronbach’s α 0.60 (frequency of sensory symptoms) to 0.90 (emotional reactions). All item groups expected to be stable had acceptable test-retest reliability (ICC = 0.71–0.83), except ‘mobility’ and ‘friendships and social interaction’ (ICC = 0.52 and 0.45). Construct validity was supported with 10 of 13 (77%) hypothesised correlations of change in the BBSIP^8?18 items corresponding with changes in external criterion measures. The responsiveness of 8 out of 10 item groups tested against an external criterion was supported (AUC = 0.71–0.92).ConclusionThe BBSIP^8?18 has acceptable reliability, validity and responsiveness supporting its use as an evaluative self-report measure of burn scar-specific HRQoL in the early post-acute phase after burn injury.     

Frailty measured by risk analysis index and adverse discharge outcomes after adult spine deformity surgery: analysis of 3104 patients from a prospective surgical registry (2011–2020)

Background ContextMeasurement of frailty with the Risk Analysis Index (RAI) has demonstrated improved outcome prediction compared to other frailty indices across the surgical literature. However, the generalizability and clinical utility of preoperative RAI scoring for prediction of postoperative morbidity after adult spinal deformity surgery is presently unknown. Thus, recent studies have called for an RAI analysis of spine deformity outcomes.PurposeThe present study sought to evaluate the discriminatory accuracy of preoperative frailty, as measured by RAI, for predicting postoperative morbidity among adult spine deformity surgery patients using data queried from a large prospective surgical registry representing over 700 hospitals from 49 US states and 11 countries.Study Design/SettingSecondary analysis of a prospective surgical registry.Patient SampleAmerican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2020).Outcome MeasuresThe primary endpoint was “adverse discharge outcome” (ADO) defined as discharge to a non-home, non-rehabilitation nursing/chronic care facility.MethodsAdult spine deformity surgeries were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2020) using diagnosis and procedure codes. The relationship between increasing preoperative RAI frailty score and increasing rate of primary endpoint (ADO) was assessed with Cochran-Armitage linear trend tests. Discriminatory accuracy was tested by computation of concordance statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.ResultsA total of 3104 patients underwent spine deformity surgery and were stratified by RAI score: 0–10: 22%, 11–15: 11%, 16–20: 29%, 21–25: 26%, 26–30: 8.0%, 31–35: 2.4%, and 36+: 1.4%. The rate of ADO was 14% (N=439/3094). The rate of ADO increased significantly with increasing RAI score (p<.0001). RAI demonstrated robust discriminatory accuracy for prediction of ADO in ROC analysis (C-statistic: 0.71, 95% CI: 0.69–0.74, p<.001). In pairwise comparison of ROC curves (DeLong test), RAI demonstrates superior discriminatory accuracy compared to the 5-factor modified frailty index (mFI-5; p<.001).ConclusionPreoperative frailty, as measured by RAI, is a robust predictor of postoperative morbidity (measured by ADO) after adult spine deformity surgery. The frailty score may be translated directly to the bedside with a user-friendly risk calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spineDeformity