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Evolution in Surgical Approach, Complications, and Outcomes in an Adult Spinal Deformity Surgery Multicenter Study Group Patient Population

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Abstract

Study Design

Retrospective review of a prospectively collected multicenter database.

Objectives

To evaluate the evolution of surgical treatment strategies, complications, and patient-reported outcomes for adult spinal deformity (ASD) patients.

Summary of Background Data

ASD surgery is associated with high complication rates. Evolving treatment strategies may reduce these risks.

Methods

Adult patients undergoing ASD surgery from 2009 to 2016 were analyzed (n = 905). Preoperative and surgical parameters were compared across years. Subgroup analysis of 436 patients with minimum two-year follow-up was also performed.

Results

From 2009 to 2016, there was a significant increase in the mean preoperative age (52 to 63.1, p < .001), body mass index (26.3 to 32.2, p = .003), Charlson Comorbidity index (1.4 to 2.2, p < .001), rate of previous spine surgery (39.8% to 53.1%, p = .01), and baseline disability (visual analog scale [VAS] back and leg pain) scores (p < .01), Oswestry Disability Index, and 22–item Scoliosis Research Society Questionnaire scores (p < .001). Preoperative Schwab sagittal alignment modifiers and overall surgical invasiveness index were similar across time. Three-column osteotomy utilization decreased from 36% in 2011 to 16.7% in 2016. Lateral lumbar interbody fusion increased from 6.4% to 24.1% (p = .004), anterior lumbar interbody fusion decreased from 22.9% to 16.7% (p = .043), and transforaminal lumbar interbody fusion/posterior lumbar interbody fusion utilization remained similar (p = .448). Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in 2012 was 84.6%, declined to 58% in 2013, and rebounded to 76.3% in 2016 (p = .006). Tranexamic acid use increased rapidly from 2009 to 2016 (13.3% to 48.6%, p < .001). Two-year follow-up sagittal vertical axis, pelvic tilt, pelvic incidence—lumbar lordosis, and maximum Cobb angles were similar across years. Intraoperative complications decreased from 33% in 2010 to 9.3% in 2016 (p < .001). Perioperative ( < 30 days, < 90 days) complications peaked in 2010 (42.7%, 46%) and decreased by 2016 (24.1%, p < .001; 29.6%, p = .007). The overall complication rate decreased from 73.2% in 2008–2014 patients to 62.6% in 2015–2016 patients (p = .03). Two-year health-related quality of life outcomes did not significantly differ across the years (p > .05).

Conclusions

From 2009 to 2016, despite an increasingly elderly, medically compromised, and obese patient population, complication rates decreased. Evolving strategies may result in improved treatment of ASD patients.

Level of Evidence

Level IV.

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Author information

Authors and Affiliations

  1. Adult Spinal Deformity Service, Department of Orthopedics, Brown University, 02912, Providence, RI, USA

    Alan H. Daniels MD & Daniel B. C. Reid MD, MPH

  2. Scripps Clinic and San Diego Center for Spinal Disorders, 4130 La Jolla Village Dr #300, 92037, La Jolla, CA, USA

    Stacie Nguyen Tran MPH, Robert Eastlack MD, Behrooz Akbarnia MD & Gregory M. Mundis Jr. MD

  3. Orthopaedics, Swedish Medical Center, 501 E Hampden Ave, 80113, Englewood, CO, USA

    Robert A. Hart MD

  4. Orthopaedics, University of California, 1 Shields Ave, 95616, Davis, CA, USA

    Eric O. Klineberg MD

  5. Orthopaedics, Denver International Spine Center, Presbyterian/St. Luke’s, Rocky Mountain Hospital for Children, 2001 N High St, 80205, Denver, CO, USA

    Shay Bess MD

  6. Orthopedics, University of Kansas Hospital, 4000 Cambridge St, 66160, Kansas City, KS, USA

    Douglas Burton MD

  7. Neurosurgery, University of Virginia Health System, 1215 Lee St, 22903, Charlottesville, VA, USA

    Justin S. Smith MD, PhD & Christopher Shaffrey MD

  8. Orthopaedics, Washington University in St. Louis, One Brookings Drive, 63130, St. Louis, MO, USA

    Munish Gupta MD & Michael Kelly MD

  9. Neurosurgery, University of California, 400 Parnassus Ave, 94122, San Francisco, CA, USA

    Christopher P. Ames MD

  10. Neurosurgery, University of Pittsburgh, 4200 Fifth Ave, 15260, Pittsburgh, PA, USA

    D. Kojo Hamilton MD

  11. Orthopaedics, Hospital for Special Surgery, 535 East 70th Street, 10021, New York, NY, USA

    Virginie LaFage PhD, Frank Schwab MD & Han Jo Kim MD

  12. Orthopaedics, New York University, 70 Washington Square South, 10012, New York, NY, USA

    Peter G. Passias MD & Themistocles Protopsaltis MD

Authors
  1. Alan H. Daniels MD
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  2. Daniel B. C. Reid MD, MPH
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  3. Stacie Nguyen Tran MPH
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  4. Robert A. Hart MD
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  5. Eric O. Klineberg MD
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  6. Shay Bess MD
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  7. Douglas Burton MD
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  8. Justin S. Smith MD, PhD
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  9. Christopher Shaffrey MD
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  10. Munish Gupta MD
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  11. Christopher P. Ames MD
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  12. D. Kojo Hamilton MD
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  13. Virginie LaFage PhD
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  14. Frank Schwab MD
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  15. Robert Eastlack MD
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  16. Behrooz Akbarnia MD
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  17. Han Jo Kim MD
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  18. Michael Kelly MD
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  19. Peter G. Passias MD
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  20. Themistocles Protopsaltis MD
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  21. Gregory M. Mundis Jr. MD
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Consortia

International Spine Study Group

Corresponding author

Correspondence to Daniel B. C. Reid MD, MPH.

Additional information

Author disclosures: AHD (grants and personal fees from Orthofix; personal fees from Stryker and SpineArt; other from Springer, outside the submitted work), DBCR (none), SNT (none), RAH (other from American Orthopaedic Association; other from Cervical Spine Research Society [CSRS] ; personal fees and other from DePuy, Globus Medical, SeaSpine, and ISSLS Textbook of the Lumbar Spine; personal fees from Medtronic; grants from Misonix; other from North America Spine Society, personal fees from Orthofix, Inc.; other from Scoliosis Research Society, Western Ortho Association, and International Spine Study Group [ISSG], outside the submitted work; in addition, RAH has a patent DePuy with royalties paid, a patent Globus Medical with royalties paid, and a patent SeaSpine with royalties paid), EOK (grants and personal fees from AO Spine and DePuy; grants from OREF; personal fees from K2M, Springer, Stryker, and Trevena, outside the submitted work), SB (grants from DePuy Synthes, during the conduct of the study; grants and personal fees from K2 Medical; personal fees from Pioneer and Allosource; grants from DePuy Synthes, Medtronic, and NuVasive, outside the submitted work), DB (grants from Bioventis; personal fees and other from DePuy; grants from Pfizer; other from Scoliosis Research Society and Spine Deformity, outside the submitted work; in addition, SB has a patent DePuy with royalties paid), 1SS (grants from DePuy Synthes/ISSG, during the conduct of the study; personal fees from Zimmer Biomet, NuVasive, K2M, and Allosource; grants from DePuy Synthes/ISSG, Neurosurgery Research and Education Foundation, and AOSpine, outside the submitted work), CS (other from American Association of Neurological Surgeons and American Board of Neurological Surgery; personal fees from Biomet; other from CSRS; grants from DePuy; personal fees from K2M and Medtronic; personal fees and other from Medtronic Sofamor Danek and NuVasive; other from Scoliosis Research Society, Spinal Deformity, and Spine; personal fees from Stryker and Zimmer, outside the submitted work; in addition, CS has a patent Zimmer with royalties paid), MG (personal fees and other from DePuy; other from European Spine lournal, Global Spine lournal, lohnson & lohnson, Proctor and Gamble, and Spine Deformity, outside the submitted work), CPA (grants and personal fees from NuVasive; personal fees from K2M, DePuy Synthes, and NociMed; grants from SeaSpine, outside the submitted work), DKH (none), VLF (grants and personal fees from DePuy; other from ISSG; personal fees from Medtronic, other from Nemaris INC and Scoliosis Research Society, outside the submitted work), FS (grants from DePuy; personal fees and other from K2M; personal fees from Medicrea, NuVasive, and Medtronic; other from Medtronic Sofamor Danek, Nemaris, Scoliosis Research Society, Spine Deformity, and ISSG; personal fees and other from Zimmer, outside the submitted work; in addition, FS has a patent K2M with royalties paid, a patent Medtronic Sofamor Danek with royalties paid, and a patent Zimmer with royalties paid), RE (other from Alphatec; grants, personal fees, nonfinancial support, and other from NuVasive; personal fees from Globus Medical and K2M; personal fees and nonfinancial support from SeaSpine; personal fees from Titan and SI Bone; other from Spine Innovation and NuTech, personal fees from Eli Lilly, outside the submitted work), BA (grants and personal fees from NuVasive; personal fees from K2M, DePuy Synthes, and NociMed; grants from SeaSpine, outside the submitted work), H1K (other from AO spine, ISSG Foundation, Scoliosis Research Society, HSS lournal, and Asian Spine lournal; personal fees from K2M and Zimmer Biomet, outside the submitted work), MK (grants from DePuy Synthes Spine, outside the submitted work), PGP (grants from DePuy Synthes, during the conduct of the study; personal fees from Medicrea, SpineWave, Zimmer Biomet, Globus, Allosource, and Aesculap; grants from CSRS, outside the submitted work), TP (grants from CSRS; personal fees from Globus Medical, Innovasis, Medicrea International, and NuVasive; grants from Zimmer, outside the submitted work), GMM (personal fees from DePuy; other from ISSG Foundation and K2M; grants, personal fees, and other from NuVasive, outside the submitted work; in addition, GMM has a patent K2M with royalties paid), ISSG (grants from DePuy Synthes Spine, K2M, NuVasive, Biomet, and Orthofix, during the conduct of the study; grants from Medtronic and Stryker, outside the submitted work).This study was funded by the International Spine Study Group Foundation (ISSGF).

IRB approval: Institutional review board approval was obtained at all participating institutions for collection and analysis of patient data.

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Daniels, A.H., Reid, D.B.C., Tran, S.N. et al. Evolution in Surgical Approach, Complications, and Outcomes in an Adult Spinal Deformity Surgery Multicenter Study Group Patient Population. Spine Deform 7, 481–488 (2019). https://doi.org/10.1016/j.jspd.2018.09.013

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  • DOI: https://doi.org/10.1016/j.jspd.2018.09.013

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