Have We Made Advancements in Optimizing Surgical Outcomes and Enhancing Recovery for Patients With High-Risk Adult Spinal Deformity Over Time?

Peter G Passias; Lara Passfall; Peter S Tretiakov; Ankita Das; Oluwatobi O Onafowokan; Justin S Smith; Virginie Lafage; Renaud Lafage; Breton Line; Jeffrey Gum; Khaled M Kebaish; Khoi D Than; Gregory Mundis; Richard Hostin; Munish Gupta; Robert K Eastlack; Dean Chou; Alexa Forman; Bassel Diebo; Alan H Daniels; Themistocles Protopsaltis; D Kojo Hamilton; Alex Soroceanu; Raymarla Pinteric; Praveen Mummaneni; Han Jo Kim; Neel Anand; Christopher P Ames; Robert Hart; Douglas Burton; Frank J Schwab; Christopher Shaffrey; Eric O Klineberg; Shay Bess; International Spine Study Group

doi:10.1227/ons.0000000000001420

Have We Made Advancements in Optimizing Surgical Outcomes and Enhancing Recovery for Patients With High-Risk Adult Spinal Deformity Over Time?

Oper Neurosurg (Hagerstown). 2024 Nov 4. doi: 10.1227/ons.0000000000001420. Online ahead of print.

Authors

Peter G Passias¹, Lara Passfall¹, Peter S Tretiakov¹, Ankita Das¹, Oluwatobi O Onafowokan¹, Justin S Smith², Virginie Lafage³, Renaud Lafage³, Breton Line⁴, Jeffrey Gum⁵, Khaled M Kebaish⁶, Khoi D Than⁷, Gregory Mundis⁸, Richard Hostin⁹, Munish Gupta¹⁰, Robert K Eastlack¹¹, Dean Chou¹², Alexa Forman¹³, Bassel Diebo¹⁴, Alan H Daniels¹⁴, Themistocles Protopsaltis¹, D Kojo Hamilton¹⁵, Alex Soroceanu¹⁶, Raymarla Pinteric⁴, Praveen Mummaneni¹², Han Jo Kim¹⁷, Neel Anand¹⁸, Christopher P Ames¹², Robert Hart¹⁹, Douglas Burton²⁰, Frank J Schwab³, Christopher Shaffrey⁷, Eric O Klineberg²¹, Shay Bess⁴; International Spine Study Group

Affiliations

¹ Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York, New York, USA.
² Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
³ Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA.
⁴ Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA.
⁵ Norton Leatherman Spine Center, Louisville, Kentucky, USA.
⁶ Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA.
⁷ Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
⁸ Division of Orthopaedic Surgery, Scripps Clinic, San Diego Center for Spinal Disorders, La Jolla, California, USA.
⁹ Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas, USA.
¹⁰ Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA.
¹¹ Division of Orthopaedic Surgery, Scripps Clinic, Louisiana Jolla, California, USA.
¹² Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
¹³ New York Spine Institute for Scoliosis and Spinal Deformity, Westbury, New York, USA.
¹⁴ Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
¹⁵ Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
¹⁶ Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada.
¹⁷ Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.
¹⁸ Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, California, USA.
¹⁹ Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA.
²⁰ Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA.
²¹ Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA.

PMID: 39589896
DOI: 10.1227/ons.0000000000001420

Abstract

Background and objectives: The spectrum of patients requiring adult spinal deformity (ASD) surgery is highly variable in baseline (BL) risk such as age, frailty, and deformity severity. Although improvements have been realized in ASD surgery over the past decade, it is unknown whether these carry over to high-risk patients. We aim to determine temporal differences in outcomes at 2 years after ASD surgery in patients stratified by BL risk.

Methods: Patients ≥18 years with complete pre- (BL) and 2-year (2Y) postoperative data from 2009 to 2018 were categorized as having undergone surgery from 2009 to 2013 [early] or from 2014 to 2018 [late]. High-risk [HR] patients met ≥2 of the criteria: (1) ++ BL pelvic incidence and lumbar lordosis or SVA by Scoliosis Research Society (SRS)-Schwab criteria, (2) elderly [≥70 years], (3) severe BL frailty, (4) high Charlson comorbidity index, (5) undergoing 3-column osteotomy, and (6) fusion of >12 levels, or >7 levels for elderly patients. Demographics, clinical outcomes, radiographic alignment targets, and complication rates were assessed by time period for high-risk patients.

Results: Of the 725 patients included, 52% (n = 377) were identified as HR. 47% (n = 338) had surgery pre-2014 [early], and 53% (n = 387) underwent surgery in 2014 or later [late]. There was a higher proportion of HR patients in Late group (56% vs 48%). Analysis by early/late status showed no significant differences in achieving improved radiographic alignment by SRS-Schwab, age-adjusted alignment goals, or global alignment and proportion proportionality by 2Y (all P > .05). Late/HR patients had significantly less poor clinical outcomes per SRS and Oswestry Disability Index (both P < .01). Late/HR patients had fewer complications (63% vs 74%, P = .025), reoperations (17% vs 30%, P = .002), and surgical infections (0.9% vs 4.3%, P = .031). Late/HR patients had lower rates of early proximal junctional kyphosis (10% vs 17%, P = .041) and proximal junctional failure (11% vs 22%, P = .003).

Conclusion: Despite operating on more high-risk patients between 2014 and 2018, surgeons effectively reduced rates of complications, mechanical failures, and reoperations, while simultaneously improving health-related quality of life.