When not to Operate in Spinal Deformity: Identifying Subsets of Patients With Simultaneous Clinical Deterioration, Major Complications, and Reoperation

Peter G Passias; Katherine E Pierce; Pooja Dave; Renaud Lafage; Virginie Lafage; Andrew J Schoenfeld; Breton Line; Juan Uribe; Richard Hostin; Alan Daniels; Robert Hart; Douglas Burton; Han Jo Kim; Gregory M Mundis; Robert Eastlack; Bassel G Diebo; Jeffrey L Gum; Christopher Shaffrey; Frank Schwab; Christopher P Ames; Justin S Smith; Shay Bess; Eric Klineberg; Munish C Gupta; D Kojo Hamilton; International Spine Study Group

doi:10.1097/BRS.0000000000004778

When not to Operate in Spinal Deformity: Identifying Subsets of Patients With Simultaneous Clinical Deterioration, Major Complications, and Reoperation

Spine (Phila Pa 1976). 2023 Nov 1;48(21):1481-1485. doi: 10.1097/BRS.0000000000004778. Epub 2023 Jul 20.

Authors

Peter G Passias¹, Katherine E Pierce¹, Pooja Dave¹, Renaud Lafage², Virginie Lafage², Andrew J Schoenfeld³, Breton Line⁴, Juan Uribe⁵, Richard Hostin⁶, Alan Daniels⁷, Robert Hart⁸, Douglas Burton⁹, Han Jo Kim², Gregory M Mundis¹⁰, Robert Eastlack¹⁰, Bassel G Diebo⁷, Jeffrey L Gum¹¹, Christopher Shaffrey¹², Frank Schwab², Christopher P Ames¹³, Justin S Smith¹⁴, Shay Bess⁴, Eric Klineberg¹⁵, Munish C Gupta¹⁶, D Kojo Hamilton¹⁷; International Spine Study Group

Affiliations

¹ Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY.
² Department of Orthopedics, Hospital for Special Surgery, New York, NY.
³ Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
⁴ Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO.
⁵ Department of Neurosurgery, University of South Florida, Tampa, FL.
⁶ Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX.
⁷ Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.
⁸ Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA.
⁹ Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas.
¹⁰ Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA.
¹¹ Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY.
¹² Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC.
¹³ Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA.
¹⁴ Department of Neurosurgery, University of Virginia, Charlottesville, VA.
¹⁵ Department of Orthopaedic Surgery, University of California, Davis, Davis, CA.
¹⁶ Department of Orthopaedic Surgery, Washington University of St Louis, St. Louis, MO.
¹⁷ Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

PMID: 37470375
DOI: 10.1097/BRS.0000000000004778

Abstract

Study design: Retrospective review of a prospectively enrolled adult spinal deformity (ASD) database.

Objective: To investigate what patient factors elevate the risk of sub-optimal outcomes after deformity correction.

Background: Currently, it is unknown what factors predict a poor outcome after adult spinal deformity surgery, which may require increased preoperative consideration and counseling.

Materials and methods: Patients >18 yrs undergoing surgery for ASD(scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK≥60°). An unsatisfactory outcome was defined by the following categories met at two years: (1) clinical: deteriorating in ODI at two years follow-up (2) complications/reoperation: having a reoperation and major complication were deemed high risk for poor outcomes postoperatively (HR). Multivariate analyses assessed predictive factors of HR patients in adult spinal deformity patients.

Results: In all, 633 adult spinal deformity (59.9 yrs, 79% F, 27.7 kg/m 2, CCI: 1.74) were included. Baseline severe Schwab modifier incidence (++): 39.2% pelvic incidence and lumbar lordosis, 28.8% sagittal vertical axis, 28.9% PT. Overall, 15.5% of patients deteriorated in ODI by two years, while 7.6% underwent reoperation and had a major complication. This categorized 11 (1.7%) as HR. HR were more comorbid in terms of arthritis (73%), heart disease (36%), and kidney disease (18%), P <0.001. Surgically, HR had greater EBL (4431ccs) and underwent more osteotomies (91%), specifically Ponte(36%) and Three Column Osteotomies(55%), which occurred more at L2(91%). HR underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all P <0.050. The multivariate regression determined a combination of a baseline Distress and Risk Assessment Method score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score ≤3, cSVA >65 mm, C2 slope >30.2°, CTPA >5.5° for an R2 value of 0.535 ( P <0.001).

Conclusions: When addressing adult spine deformities, poor outcomes tend to occur in severely comorbid patients with major baseline psychological distress scores, poor neurologic function, and concomitant cervical malalignment.