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BACKGROUND:High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed. OBJECTIVE:To compare outcomes of operative and nonoperative treatment for ASD. METHODS:This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence–to–lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up. RESULTS:Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence–to–lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications. CONCLUSION:Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability. ABBREVIATIONS:ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisMCID, minimal clinically important differenceNRS, numeric rating scaleODI, Oswestry Disability IndexPI, pelvic incidenceSF-36, Short Form-36SRS-22r, Scoliosis Research Society-22rSVA, sagittal vertical axis

Study Design: Retrospective chart review. Objective: The goal of this study is to examine the relationship between global alignment and proportion (GAP) score and postoperative orthoses with likelihood of developing proximal junctional kyphosis (PJK). Methods: Patients who underwent thoracic or lumbar fusions of ≥4 levels for adult spinal deformity (ASD) with 1-year post-operative alignment x-rays were included. Chart review was conducted to determine spinopelvic alignment parameters, PJK, and reoperation. Results: A total of 81 patients were included; baseline and 1-year postoperative alignment did not differ between patients with and without PJK. There was no PJK in 53.1%, 29.6% had PJK from 10-20°, and 17.3% had severe PJK over 20° (sPJK). At baseline, 80% of patients had severely disproportioned GAP, 13.75% moderate, 6.25% proportioned. GAP improved across the population, but improved GAP was not associated with sPJK. Greater correction of the upper instrumented vertebra to pelvic angle (UIV-PA) was associated with a larger PJK angle (PJKA) change (R = -0.28) as was the 1 year T1-upper instrumented vertebra (T1-UIV) angle (R = 0.30), both P < .05. GAP change was not correlated with PJKA change. Postoperative orthoses were used in 46% of patients and did not impact sPJK. Conclusions: There was no correlation between PJK and GAP or change in GAP. Greater correction of UIV-PA and larger postop T1-UIV was associated with greater PJKA change; suggesting that the greater alignment correction led to greater likelihood of failure. Postoperative orthoses had no impact on PJK.

BACKGROUND:The maintenance of horizontal gaze is an essential function of upright posture and global sagittal spinal alignment. Horizontal gaze is classically measured by the chin-brow vertical angle (CBVA), which is not readily measured on most lateral spine radiographs. OBJECTIVE:To evaluate relations between CBVA and the slope of the line of sight, the slope of McGregorʼs line (McGS), and Oswestry Disability Index. METHODS:Patients were identified from a single center database of 531 spine patients who underwent full-body EOS x-rays. Correlations between CBVA, the slope of the line of sight, and McGS were assessed. Using a quadratic regression with Oswestry Disability Index and CBVA, windows of low disability were identified. Comparison of sagittal spinopelvic parameters was carried out between patients with “ascending gaze” and “neutral position.” RESULTS:Three hundred three patients were included (74% female, mean age 54.8 years, body mass index 26.6 ± 6.0 kg/m). CBVA strongly correlated with the slope of the line of sight (r = 0.996) and McGS (r = 0.862). Regression studies between Oswestry Disability Index and CBVA yielded a range of values corresponding to low disability (−4.7 degrees to 17.7 degrees). Similarly, a low disability range for the slope of the line of sight (−5.1 degrees to 18.5 degrees) and McGS (−5.7 degrees to 14.3 degrees) was computed. Patients with “ascending gaze” had a worse spinopelvic alignment than “neutral position” patients. CONCLUSION:The slope of the line of sight and McGS correlated strongly with CBVA and can be used as surrogate measures. The range of values for these measures corresponding to low disability was identified. These values can be used as a general guideline to assess alignment for diagnostic purposes. Cervical compensatory mechanism may modify the natural head position in sagittally misaligned patients. ABBREVIATIONS:CBVA, chin-brow vertical angleHRQoL, health-related quality of lifeMcGS, slope of McGregorʼs lineODI, Oswestry Disability IndexSLs, slope of the line of sight

PurposePredictors of long-term opioid usage in TLIF patients have not been previously explored in the literature. We examined the effect of pre-operative narcotic use in addition to other predictors of the pattern and duration of post-operative narcotic usage.MethodsWe conducted a retrospective cohort study at a single academic institution of patients undergoing a one- or two-level primary TLIF between 2014 and 2017. Total oral morphine milligram equivalents (MMEs) for inpatient use were calculated and used as the common unit of comparison.ResultsA multivariate binary logistic regression (R2 = 0.547, specificity 95%, sensitivity 58%) demonstrated that a psychiatric or chronic pain diagnosis (OR 3.95, p = 0.013, 95% CI 1.34–11.6), pre-operative opioid use (OR 8.65, p < 0.001, 95% CI 2.59–29.0), ASA class (OR 2.95, p = 0.025, 95% CI 1.14–7.63), and inpatient total MME (1.002, p < 0.001, 95% CI 1.001–1.003) were positive predictors of prolonged opioid use at 6-month follow-up, while inpatient muscle relaxant use (OR 0.327, p = 0.049, 95% CI 0.108–0.994) decreased the probability of prolonged opioid use. Patients in the pre-operative opioid use group had a significantly higher rate of opioid usage at 6 weeks (79% vs. 46%, p < 0.001), 3 months (51% vs. 14%, p < 0.001), and 6 months (40% vs. 5%, p < 0.001).ConclusionsPre-operative opioid usage is associated with higher total inpatient opioid use and a significantly higher risk of long-term opiate usage at 6 months. Approximately 40% of pre-operative narcotic users will continue to consume narcotics at 6-month follow-up, compared with 5% of narcotic-naïve patients.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

ObjectiveThe aim of this study is to present our technique for a large focal correction of a partially flexible dropped head deformity through combined anterior and posterior osteotomies, as well as anterior soft tissue releases.MethodsOne patient with dropped head deformity underwent an anterior and posterior osteotomy with anterior soft tissue release.ResultsThe patient recovered well, with postoperative radiographs demonstrating significant improvement in coronal and sagittal alignment. His C2–C7 sagittal vertical axis improved from 7.5 cm preoperatively to less than 4 cm postoperatively and his C2–C7 sagittal Cobb improved from 35° of kyphosis to 10° of lordosis.ConclusionIn this report, we present our technique for a large focal correction of a partially flexible dropped head deformity through combined anterior and posterior osteotomies and anterior soft tissue releases. These more conservative osteotomies permitted gradual deformity correction and alleviated the need for pedicle subtraction osteotomy. We were able to restore horizontal gaze and improve sagittal malalignment. Although the technique we present here is one of many possible options for managing the deformity, we believe this combined approach is safe and effective and well tolerated by patients.

Study Design: Retrospective clinical review. Objective: To assess the use of intraoperative computed tomography (CT) image-guided navigation (IGN) and robotic assistance in posterior lumbar surgery and their relationship with patient radiation exposure and perioperative outcomes. Methods: Patients ≥18 years old undergoing 1- to 2-level transforaminal lateral interbody fusion in 12-month period were included. Chart review was performed for pre- and intraoperative data on radiation dose and perioperative outcomes. All radiation doses are quantified in milliGrays (mGy). Univariate analysis and multivariate logistic regression analysis were utilized for categorical variables. One-way analysis of variance with post hoc Tukey test was used for continuous variables. Results: A total of 165 patients were assessed: 12 IGN, 62 robotic, 56 open, 35 fluoroscopically guided minimally invasive surgery (MIS). There was a lower proportion of women in open and MIS groups (P = .010). There were more younger patients in the MIS group (P < .001). MIS group had the lowest mean posterior levels fused (P = .015). Total-procedure radiation, total-procedure radiation/level fused, and intraoperative radiation was the lowest in the open group and highest in the MIS group compared with IGN and robotic groups (all P < .001). Higher proportion of robotic and lower proportion of MIS patients had preoperative CT (P < .001). Estimated blood loss (P = .002) and hospital length of stay (P = .039) were lowest in the MIS group. Highest operative time was observed for IGN patients (P < .001). No differences were observed in body mass index, Charlson Comorbidity Index, and postoperative complications (P = .313, .051, and .644, respectively). Conclusion: IGN and robotic assistance in posterior lumbar fusion were associated with higher intraoperative and total-procedure radiation exposure than open cases without IGN/robotics, but significantly less than MIS without IGN/robotics, without differences in perioperative outcomes. Fluoro-MIS procedures reported highest radiation exposure to patient, and of equal concern is that the proportion of total radiation dose also applied to the surgeon and operating room staff in fluoro-MIS group is higher than in IGN/robotics and open groups.

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.

PurposeThis study compares perioperative and 1-year outcomes of lateral decubitus single position circumferential fusion (L-SPS) versus minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) for degenerative pathologies.MethodsMulticenter retrospective chart review of patients undergoing AP fusion with L-SPS or MIS TLIF. Demographics and clinical and radiographic outcomes were compared using independent samples t tests and chi-squared analyses with significance set at p < 0.05.ResultsA total of 445 patients were included: 353 L-SPS, 92 MIS TLIF. The L-SPS cohort was significantly older with fewer diabetics and more levels fused. The L-SPS cohort had significantly shorter operative time, blood loss, radiation dosage, and length of stay compared to MIS TLIF. 1-year follow-up showed that the L-SPS cohort had higher rates of fusion (97.87% vs. 81.11%; p = 0.006) and lower rates of subsidence (6.38% vs. 38.46%; p < 0.001) compared with MIS TLIF. There were significantly fewer returns to the OR within 1 year for early mechanical failures with L-SPS (0.0% vs. 5.4%; p < 0.001). 1-year radiographic outcomes revealed that the L-SPS cohort had a greater LL (56.6 ± 12.5 vs. 51.1 ± 15.9; p = 0.004), smaller PI-LL mismatch (0.2 ± 13.0 vs. 5.5 ± 10.5; p = 0.004). There were no significant differences in amount of change in VAS scores between cohorts.Similar results were seen after propensity-matched analysis and sub-analysis of cases including L5-S1.ConclusionsL-SPS improves perioperative outcomes and does not compromise clinical or radiographic results at 1-year follow-up compared with MIS TLIF. There may be decreased rates of early mechanical failure with L-SPS.

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.