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Background Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described. Study design/setting This is a retrospective study on a prospectively enrolled, complex ASD database. Purpose This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications. Methods Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO. Results 648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m 2 , levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6–10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3–21; G4–24; G5–27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086). Conclusion Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.

Study Design/Setting Retrospective cohort study. Objective Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery. Methods ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility. Results By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001). Conclusions The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions. Level of evidence: III

Abstract BACKGROUND Despite reports showing positive long-term functional outcomes following adult spinal deformity (ASD)-corrective surgery, it is unclear which factors affect the durability of these outcomes. OBJECTIVE To assess durability of functional gains following ASD-corrective surgery; determine predictors for postoperative loss of functionality. METHODS Surgical ASD patients > 18 yr with 3-yr Oswestry Disability Index (ODI) follow-up, and 1-yr postoperative (1Y) ODI scores reaching substantial clinical benefit (SCB) threshold (SCB < 31.3 points). Patients were grouped: those sustaining ODI at SCB threshold beyond 1Y (sustained functionality) and those not (functional decline). Kaplan-Meier survival analysis determined postoperative durability of functionality. Multivariate Cox regression assessed the relationship between patient/surgical factors and functional decline, accounting for age, sex, and levels fused. RESULTS All 166 included patients showed baseline to 1Y functional improvement (mean ODI: 35.3 ± 16.5-13.6 ± 9.2, P < .001). Durability of satisfactory functional outcomes following the 1Y postoperative interval was 88.6% at 2-yr postoperative, and 71.1% at 3-yr postoperative (3Y). Those sustaining functionality after 1Y had lower baseline C2-S1 sagittal vertical axis (SVA) and T1 slope (both P < .05), and lower 1Y thoracic kyphosis (P = .035). From 1Y to 3Y, patients who sustained functionality showed smaller changes in alignment: pelvic incidence minus lumbar lordosis, SVA, T1 slope minus cervical lordosis, and C2-C7 SVA (all P < .05). Those sustaining functionality beyond 1Y were also younger, less frail at 1Y, and had lower rates of baseline osteoporosis, hypertension, and lung disease (all P < .05). Lung disease (Hazard Ratio:4.8 [1.4-16.4]), 1Y frailty (HR:1.4 [1.1-1.9]), and posterior approach (HR:2.6 [1.2-5.8]) were associated with more rapid decline. CONCLUSION Seventy-one percent of ASD patients maintained satisfactory functional outcomes by 3Y. Of those who failed to sustain functionality, the largest functional decline occurred 3-yr postoperatively. Frailty, preoperative comorbidities, and surgical approach affected durability of functional gains following surgery.

PurposeAI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics—this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology.MethodsThis was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map—a form of artificial neural network frequently employed in unsupervised classification tasks—was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared.ResultsQualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not.ConclusionsThis study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity.Level of Evidence IVDiagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Abstract BACKGROUND Few reports focus on adults with severe scoliosis. OBJECTIVE To report surgical outcomes and complications for adults with severe scoliosis. METHODS A multicenter, retrospective review was performed on operatively treated adults with severe scoliosis (minimum coronal Cobb: thoracic [TH] ≥ 75°, thoracolumbar [TL] ≥ 50°, lumbar [L] ≥ 50°). RESULTS Of 178 consecutive patients, 146 (82%; TH = 8, TL = 88, L = 50) achieved minimum 2-yr follow-up (mean age = 53.9 ± 13.2 yr, 92% women). Operative details included posterior-only (58%), 3-column osteotomy (14%), iliac fixation (72%), and mean posterior fusion = 13.2 ± 3.7 levels. Global coronal alignment (3.8 to 2.8 cm, P = .001) and maximum coronal Cobb improved significantly (P ≤.020): TH (84º to 57º; correction = 32%), TL (67º to 35º; correction = 48%), L (61º to 29º; correction = 53%). Sagittal alignment improved significantly (P < .001), most notably for L: C7-sagittal vertical axis 6.7 to 2.5 cm, pelvic incidence-lumbar lordosis mismatch 18º to 3º. Health-related quality-of-life (HRQL) improved significantly (P < .001), most notably for L: Oswestry Disability Index (44.4 ± 20.5 to 26.1 ± 18.3), Short Form-36 Physical Component Summary (30.2 ± 10.8 to 39.9 ± 9.8), and Scoliosis Research Society-22r Total (2.9 ± 0.7 to 3.8 ± 0.7). Minimal clinically important difference and substantial clinical benefit thresholds were achieved in 36% to 75% and 29% to 51%, respectively. Ninety-four (64%) patients had ≥1 complication (total = 191, 92 minor/99 major, most common = rod fracture [13.0%]). Fifty-seven reoperations were performed in 37 (25.3%) patients, with most common indications deep wound infection (11) and rod fracture (10). CONCLUSION Although results demonstrated high rates of complications, operative treatment of adults with severe scoliosis was associated with significant improvements in mean HRQL outcome measures for the study cohort at minimum 2-yr follow-up. Graphical Abstract Graphical Abstract

PurposeWhile the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management.Methods1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring. Free-text responses were analyzed and collated into common themes. Data were analyzed using Microsoft Excel 2013.ResultsOf 218 respondents; 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing. 99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both %-Cobb correction and fit criteria to evaluate brace adequacy. In contrast, other aspects of brace management demonstrated a high degree of practice variability. This was seen with a radiographic assessment of maturity level, hours prescribed, timing and frequency of radiographic evaluation, the use of nighttime bracing only, and the method and timing of brace discontinuation.ConclusionAlthough there is consensus in brace management amongst SRS members with respect to brace initiation and evaluation of adequacy, there is striking variability in how bracing for AIS is used. This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS.Level of evidenceIII.

Study DesignMulticenter, retrospective radiographic analysis.ObjectivesTo evaluate the impact that preoperative spinopelvic parameters have on postoperative sagittal vertical axis (SVA). The researchers hypothesized that patients with a large preoperative pelvic tilt (PT) would require more extensive lumbar pedicle subtraction osteotomy (LPSO) procedures to reestablish anatomic postoperative SVA than patients with normal preoperative PT.Summary of Background DataRestoration of anatomic sagittal spinal alignment has been demonstrated to improve clinical outcomes. However, the degree to which spinopelvic parameters contribute to sagittal spinal malalignment is poorly understood.MethodsMulticenter, retrospective analysis of 183 consecutively enrolled adult spinal deformity patients treated with LPSO procedures for correction of sagittal malalignment. Preoperative and postoperative freestanding full-length sagittal X-rays were analyzed for regional curves, pelvic parameters, and global alignment. Only patients with a preoperative SVA greater than 10 cm and a postoperative SVA less than 5 cm were retained for analysis. Patients were divided into 2 groups according to preoperative PT (low PT, less than 30°; and high PT, 3⩾30°). Independent t test analysis was used to determine differences in correction required to achieve postoperative SVA less than 5 cm.ResultsA total of 55 patients were identified for analysis. Low PT (n = 30) had lower preoperative PT than high PT (n = 25; 25° vs. 42°, respectively; p <.001). Analysis of the osteotomy performed demonstrated that the high PT group required a larger osteotomy resection (30° vs. 23°; p =.039) and a larger correction of lumbar lordosis (−43° vs. −31°;p =.006) to achieve an acceptable postoperative SVA (less than 5 cm).ConclusionsThis study demonstrates that patients with high PT in conjunction with sagittal spinal malalignment require larger lumbar osteotomy procedures, including a greater osteotomy resection and larger lumbar lordosis correction, to obtain a satisfactory postoperative SVA. Surgeons performing LPSO procedures must evaluate preoperative spinopelvic parameters, including PT, to avoid undercorrection and residual deformity after complex sagittal realignment procedures.

Purpose To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS). Methods Multicenter comparative cohort study . Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input–output difference (IOD), and normalized input–output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes. Results Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation ( p  < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF ( ρ  = 0.221, p  < 0.001), IOD ( ρ  = 0.115, p  = 0.001) and IOR ( ρ  = −0.138, p  < 0.001); IV fluid-related complications and tIVF ( p  = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD ( p  < 0.001 each); extended ICU stay and tIVF ( p  < 0.001), nIVF ( p  = 0.010) and IOD ( p  < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF ( p  < 0.001) and nIVF ( p  = 0.003); ICU stay and IOR ( p  = 0.002), extended ICU stay and tIVF ( p  = 0.004). Conclusion Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes. Level of evidence : III.

Purpose Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. Methods ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. Results Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p  = 0.01), lower surgical invasiveness (− 30; p  < 0.001), and shorter OR time (− 35 min; p  = 0.01). Index and total costs were 20% lower in the TL than in the UT group ( p  < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p  = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain ( p  = 0.03) than UT fusions. Conclusion In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. Level of evidence III.

Purpose To determine the proportions of patients returning to work at various points after adult spinal deformity (ASD) surgery and the associations between surgical invasiveness and time to return to work. Methods Using a multicenter database of patients treated surgically for ASD from 2008 to 2015, we identified 188 patients (mean age 51 ± 15 years) who self-reported as employed preoperatively and had 2-year follow-up. Per the ASD–Surgical and Radiographical Invasiveness Index (ASD–SR), 118 patients (63%) underwent high-invasiveness (HI) surgery (ASD–SR ≥ 100) and 70 (37%) had low-invasiveness (LI) surgery (ASD–SR < 100). Patients who self-reported ≥ 75% normal level of work/school activity were considered to be working full time. Chi-squared and Fisher exact tests were used to compare categorical variables ( α  = .05). Results Preoperatively, 69% of employed patients worked full time. Postoperatively, 15% of employed patients were full time at 6 weeks, 70% at 6 months, 83% at 1 year, and 84% at 2 years. Percentage of employed patients working full time at 2 years was greater than preoperatively ( p  < .001); percentage of patients returning to full time at 6 weeks was lower in the HI (5%) than in the LI group (19%) ( p  = .03), a difference not significant at later points. Conclusions Most adults returned to full-time work after ASD surgery. A smaller percentage of patients in the HI group than in the LI group returned to full-time work at 6 weeks. Patients employed full time preoperatively will likely return to full-time employment after ASD surgery. Level of evidence: III.