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Study Design: Retrospective cohort study. Objectives: Sarcopenia is a risk factor for medical complications following spine surgery. However, the role of sarcopenia as a risk factor for proximal junctional disease (PJD) remains undefined. This study evaluates whether sarcopenia is an independent predictor of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery. Methods: ASD patients who underwent thoracic spine to pelvis fusion with 2-year clinical and radiographic follow-up were reviewed for development of PJK and PJD. Average psoas cross-sectional area on preoperative axial computed tomography or magnetic resonance imaging at L4 was recorded. Previously described PJD risk factors were assessed for each patient, and multivariate linear regression was performed to identify independent risk factors for PJK and PJF. Disease-specific thresholds were calculated for sarcopenia based on psoas cross-sectional area. Results: Of 32 patients, PJK and PJF occurred in 20 (62.5%) and 12 (37.5%), respectively. Multivariate analysis demonstrated psoas cross-sectional area to be the most powerful independent predictor of PJK (P = .02) and PJF (P = .009). Setting ASD disease–specific psoas cross-sectional area thresholds of <12 cm2 in men and <8 cm2 in women resulted in a PJF rate of 69.2% for patients below these thresholds, relative to 15.8% for those above the thresholds. Conclusions: Sarcopenia is an independent, modifiable predictor of PJK and PJF, and is easily assessed on standard preoperative computed tomography or magnetic resonance imaging. Surgeons should include sarcopenia in preoperative risk assessment and consider added measures to avoid PJF in sarcopenic patients.

Degenerative cervical myelopathy (DCM) is a clinical diagnosis based on history, physical exam, and imaging, but standardized criteria have not been established, contributing to diagnostic delays. We conducted a prospective study of DCM and healthy subjects that comprehensively evaluated symptoms, patient-reported and clinician-administered outcome measures, and physical assessments of motor and sensory function.Diagnostic utility was evaluated using Youden’s Index (YI=sensitivity+specificity-1). 139 DCM patients and 108 age-matched healthy subjects were compared. Distinguishing symptoms included neck pain (YI=63%), upper extremity (UE) numbness (YI=57%), hand clumsiness (YI=50%), walking imbalance (YI=50%), and UE weakness (YI=46%). Questionnaires performed well including mJOA (YI=72%), NDI (YI=63%), and EQ-5D (YI=57%). Physical testing showed best results with UE reflexes (YI=54%), strength in 5 UE muscle groups (YI=53%), Berg Balance scale (YI=50%), self-paced walking velocity (YI=48%), and tandem gait assessment (YI=40%). Hand dexterity, strength dynamometry, and testing of 5 sensory modalities demonstrated poor diagnostic utility. Diagnosis of DCM is challenging, but key symptoms include neck pain, UE weakness, and those captured by the mJOA (particularly UE numbness, hand clumsiness, and walking imbalance). Physical testing of reflexes, manual motor testing, and gait/balance are useful to confirm the diagnosis. These findings offer guidance for clinicians and the development of diagnostic criteria.

ABSTRACT BACKGROUND Distal junctional kyphosis (DJK) development after cervical deformity (CD)-corrective surgery is a growing concern for surgeons and patients. Few studies have investigated risk factors that predict the occurrence of DJK. OBJECTIVE To predict DJK development after CD surgery using predictive modeling. METHODS CD criteria was at least one of the following: C2-C7 Coronal/Cobb > 10°, C2-7 sagittal vertical axis (cSVA) > 4 cm, chin-brow vertical angle > 25°. DJK was defined as the development of an angle <−10° from the end of fusion construct to the second distal vertebra, and change in this angle by <−10° from baseline to postoperative. Baseline demographic, clinical, and surgical information were used to predict the occurrence of DJK using generalized linear modeling both as one overall model and as submodels using baseline demographic and clinical predictors or surgical predictors. RESULTS One hundred seventeen CD patients were included. At any postoperative visit up to 1 yr, 23.1% of CD patients developed DJK. DJK was predicted with high accuracy using a combination of baseline demographic, clinical, and surgical factors by the following factors: preoperative neurological deficit, use of transition rod, C2-C7 lordosis (CL)<−12°, T1 slope minus CL > 31°, and cSVA > 54 mm. In the model using only baseline demographic/clinical predictors of DJK, presence of comorbidities, presence of baseline neurological deficit, and high preoperative C2-T3 angle were included in the final model (area under the curve = 87%). The final model using only surgical predictors for DJK included combined approach, posterior upper instrumented vertebrae below C4, use of transition rod, lack of anterior corpectomy, more than 3 posterior osteotomies, and performance of a 3-column osteotomy. CONCLUSION Preoperative assessment and consideration should be given to these factors that are predictive of DJK to mitigate poor outcomes.

This study was a retrospective multi-center comparative cohort study. A retrospective institutional database of operative adult spinal deformity patients was utilized. All fusions > 5 vertebral levels and including the sacrum/pelvis were eligible for inclusion. Revisions, 3 column osteotomies, and patients with < 2-year clinical follow-up were excluded. Patients were separated into 3 groups based on surgical approach: 1) posterior spinal fusion without interbody (PSF), 2) PSF with interbody (PSF-IB), and 3) anteroposterior (AP) fusion (anterior lumbar interbody fusion or lateral lumbar interbody fusion with posterior screw fixation). Intraoperative, radiographic, and clinical outcomes, as well as complications, were compared between groups with ANOVA and χ tests. One-hundred and thirty-eight patients were included for study (PSF, n = 37; PSF-IB, n = 44; AP, n = 57). Intraoperatively, estimated blood loss was similar between groups (p = 0.171). However, the AP group had longer operative times (547.5 min) compared to PSF (385.1) and PSF-IB (370.7) (p < 0.001). Additionally, fusion length was shorter in PSF-IB (11.4) compared to AP (13.6) and PSF (12.9) (p = 0.004). There were no differences between the groups in terms of change in alignment from preoperative to 2 years postoperative. There were no differences in clinical outcomes. While postoperative complications were largely similar between groups, operative complications were higher in the AP group (31.6%) compared to the PSF (5.4%) and PSF-IB (9.1) groups (p < 0.001). While there were differences in intraoperative outcomes (operative time and fusion length), there were no differences in postoperative clinical or radiographic outcomes. AP fusion was associated with a higher rate of operative complications.

BackgroundCerebral spinal fluid (CSF) dynamics are complex and changes in spinal anatomy may influence the rostrocaudal movement of intrathecal medications. We present the first reported case demonstrating that acute cervical spinal stenosis may impede the distribution of adjacent intrathecal medications, and that correction of such stenosis and the resulting changes in CSF flow may necessitate significant adjustments in the intrathecal infusates.Case presentationWe present a case of a 60-year-old male patient with a cervicothoracic intrathecal pump (ITP) infusing morphine, bupivacaine, and baclofen for chronic neck pain. The alert and oriented patient had a recent fall resulting in an acute severe cervical stenosis and cord compression which required urgent surgical decompression. Postoperatively, after the cervical decompression, the patient had significant altered mental status requiring a naloxone infusion. Multiple attempts to reduce the naloxone infusion were initially not successful due to worsened somnolence. The previously tolerated ITP medications were continuously reduced over the next 14 days, allowing concomitant decrease and eventual cessation of the naloxone infusion while maintaining patient mental status. The only opioids the patient received during this period were from the ITP.ConclusionsThis case presents clinical evidence that severe spinal stenosis may impede the rostral CSF distribution of intrathecal medications. Intrathecal medications previously tolerated by patients prior to decompression may need to be significantly reduced in the postoperative period.

Purpose To investigate the impact of the Global Alignment and Proportion (GAP) score components on patient outcomes in Adult Spine Deformity (ASD) surgery. Methods Patients included underwent assessment via the GAP score and its individual components: pelvic version (GAP PV), lumbar lordosis (GAP LL), lumbar distribution index (GAP LDI) and spinopelvic component (GAP SP). Multivariable analyses assessed the association between alignment in these components and clinical outcomes in ASD patients. Results 762 ASD patients met inclusion criteria. Alignment in GAP SP independently predicted meeting MCID for SR-22S and ODI and was associated with a lower likelihood of developing mechanical complications. Patients aligned in GAP SP were less likely to develop proximal junctional kyphosis (OR 0.42, 0.26–0.73, p  = 0.01) and PJF (OR 0.3, 0.13–0.74, p  = 0.01). Proportioned alignment in GAP SP with disproportioned alignment in GAP LDI contributed to an increased risk of PJK and PJF (OR 2.67, 95% CI 1.95–6.82, p  = 0.045). There was no significant association of GAP SP proportionality and GAP RPV (OR 1.1, 0.86–2.15, p  = 0.253) or GAP LL (OR 1.34, 0.78–4.23, p  = 0.673) disproportionality with outcomes. Disproportioned alignment in GAP SP but proportioned alignment in both GAP LL and GAP LDI was associated with decreased likelihood of PJK (OR 0.53, 95% CI 0.39–0.94, p  = 0.02) and PJF (OR 0.31, 95% CI 0.19–0.67, p  = 0.001). Conclusion The spinopelvic component of the GAP score is the most significant independent predictor of clinical outcomes. Its interaction with the other components of the GAP score also aids assessment of the risk for mechanical complications.

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.

Purpose: The aim is to investigate the relationship between cervical parameters and the modified Japanese Orthopedic Association scale (mJOA). Materials and Methods: Surgical adult cervical deformity (CD) patients were included in this retrospective analysis. After determining data followed a parametric distribution through the Shapiro-Wilk Normality (P = 0.15, P > 0.05), Pearson correlations were run for radiographic parameters and mJOA. For significant correlations, logistic regressions were performed to determine a threshold of radiographic measures for which the correlation with mJOA scores was most significant. mJOA score of 14 and <12 reported cut-off values for moderate (M) and severe (S) disability. New modifiers were compared to an existing classification using Spearman's rho and logistic regression analyses to predict outcomes up to 2 years. Results: A total of 123 CD patients were included (60.5 years, 65%F, 29.1 kg/m2). For significant baseline factors from Pearson correlations, the following thresholds were predicted: MGS (M:-12 to-9° and 0°-19°, P = 0.020; S: >19° and <−12°, χ2 = 4.291, P = 0.036), TS-CL (M: 26°to 45°, P = 0.201; S: >45°, χ2 = 7.8, P = 0.005), CL (M:-21° to 3°, χ2 = 8.947, P = 0.004; S: <−21°, χ2 = 9.3, P = 0.009), C2-T3 (M: −35° to −25°, χ2 = 5.485, P = 0.046; S: <−35°, χ2 = 4.1, P = 0.041), C2 Slope (M: 33° to 49°, P = 0.122; S: >49°, χ2 = 5.7, P = 0.008), and Frailty (Mild: 0.18-0.27, P = 0.129; Severe: >0.27, P = 0.002). Compared to existing Ames- International Spine Study Group classification, the novel thresholds demonstrated significant predictive value for reoperation and mortality up to 2 years. Conclusions: Collectively, these radiographic values can be utilized in refining existing classifications and developing collective understanding of severity and surgical targets in corrective surgery for adult CD.

Purpose Previous work comparing ASD to a normative population demonstrated that a large proportion of lumbar lordosis is lost proximally (L1-L4). The current study expands on these findings by collectively investigating regional angles and spinal contours. Methods 119 asymptomatic volunteers with full-body free-standing radiographs were used to identify age-and-PI models of each Vertebra Pelvic Angle (VPA) from L5 to T10. These formulas were then applied to a cohort of primary surgical ASD patients without coronal malalignment. Loss of lumbar lordosis (LL) was defined as the offset between age-and-PI normative value and pre-operative alignment. Spine shapes defined by VPAs were compared and analyzed using paired t-tests. Results 362 ASD patients were identified (age = 64.4 ± 13, 57.1% females). Compared to their age-and-PI normative values, patients demonstrated a significant loss in LL of 17 ± 19° in the following distribution: 14.1% had “No loss” (mean = 0.1 ± 2.3), 22.9% with 10°-loss (mean = 9.9 ± 2.9), 22.1% with 20°-loss (mean = 20.0 ± 2.8), and 29.3% with 30°-loss (mean = 33.8 ± 6.0). “No loss” patients’ spine was slightly posterior to the normative shape from L4 to T10 (VPA difference of 2°), while superimposed on the normative one from S1 to L2 and became anterior at L1 in the “10°-loss” group. As LL loss increased, ASD and normative shapes offset extended caudally to L3 for the “20°-loss” group and L4 for the “30°-loss” group. Conclusion As LL loss increases, the difference between ASD and normative shapes first occurs proximally and then progresses incrementally caudally. Understanding spinal contour and LL loss location may be key to achieving sustainable correction by identifying optimal and personalized postoperative shapes.