TY - JOUR
T1 - Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity
T2 - Analysis of 182 patients
AU - International Spine Study Group
AU - Scheer, Justin K.
AU - Passias, Peter G.
AU - Sorocean, Alexandra M.
AU - Boniello, Anthony J.
AU - Mundis, Gregory M.
AU - Klineberg, Eric
AU - Kim, Han Jo
AU - Protopsaltis, Themistocles S.
AU - Gupta, Munish
AU - Bess, Shay
AU - Shaffrey, Christopher I.
AU - Schwab, Frank
AU - Lafage, Virginie
AU - Smith, Justin S.
AU - Ames, Christopher P.
N1 - Funding Information:
Funding for the International Spine Study Group Foundation, through which this study was conducted, is obtained through research grants from DePuy Spine and individual donations. Dr. Ames is an employee of UCSF. He is a consultant for DePuy, Stryker, and Medtronic. He has direct stock ownership in Doctors Research Group and Baxano Surgical. He is a patent holder for Fish and Richardson, P.C. He receives royalties from Aesculap and Biomet Spine. Dr. Smith is a consultant for Biomet, NuVasive, Globus, Cerapedics, and DePuy Synthes. He receives royalties from Biomet and research support from DePuy-Synthes. He has received clinical or research support for this study (includes equipment or material) from DePuy-Synthes. Dr. Lafage has direct stock ownership in Nemaris and is a consultant for Medicrea. She receives research support from DePuy, SRS, ISSG, and NIH. She is a speaker/teacher for DePuy, K2M, NuVasive, and Nemaris. Dr. Schwab has direct stock ownership in Nemaris. He is a consultant for MSD, K2M, DePuy, and Medicrea. He receives research support from DePuy, MSD, and AOSpine. He is a patent holder for MSD, Nemaris, K2M, and NuVasive. He is a speaker/teacher for MSD, Nemaris, and K2M. Dr. Gupta has direct stock ownership in Johnson and Johnson, Proctor and Gamble, Pfizer, and Pioneer. He is a consultant for DePuy-Synthes and Medicrea. He is treasurer for FOSA and a board member for SRS. Dr. Bess is a consultant for NuVasive, K2M, and Allosource. He has received clinical or research support for this study (includes equipment or material) from DePuy Spine and receives other research support from Medtronic and Innovasis. Dr. Mundis is a consultant for NuVasive, K2M, Misonix, and Medicrea. He is a board member for SOLAS. Dr. Klineberg receives speaker fees and fellowship research grants from DePuy-Synthes and AOSpine. He also received a fellowship grant from OREF. Dr. Protopsaltis is a consultant for Medicrea and Biomet Spine. He receives research support from Zimmer Spine. Dr. Shaffrey is a consultant for Biomet, Medtronic, NuVasive, and Stryker. He has direct stock ownership in NuVasive and is a patent holder for Biomet and NuVasive. He receives royalties from Biomet, Medtronic, and NuVasive.
Publisher Copyright:
©AANS, 2016.
PY - 2016/1
Y1 - 2016/1
N2 - OBJECTIVE: A high prevalence of cervical deformity (CD) has been identified among adult patients with thoracolumbar spinal deformity undergoing surgical treatment. The clinical impact of this is uncertain. This study aimed to quantify the differences in patient-reported outcomes among patients with adult spinal deformity (ASD) based on presence of CD prior to treatment. METHODS: A retrospective review was conducted of a multicenter prospective database of patients with ASD who underwent surgical treatment with 2-year follow-up. Patients were grouped by the presence of preoperative CD: 1) cervical positive sagittal malalignment (CPSM) C2-7 sagittal vertical axis ≥ 4 cm; 2) cervical kyphosis (CK) C2-7 angle > 0; 3) CPSM and CK (BOTH); and 4) no baseline CD (NONE). Health-related quality of life (HRQOL) scores included the Physical Component Summary and Mental Component Summary (PCS and MCS) scores of the 36-Item Short Form Health Survey (SF-36), Oswestry Disability Index (ODI), Scoliosis Research Society-22 questionnaire (SRS-22), and minimum clinically important difference (MCID) of these scores at 2 years. Standard radiographic measurements were conducted for cervical, thoracic, and thoracolumbar parameters. RESULTS: One hundred eighty-two patients were included in this study: CPSM, 45; CK, 37; BOTH, 16; and NONE, 84. Patients with preoperative CD and those without had similar baseline thoracolumbar radiographic measurements and similar correction rates at 2 years. Patients with and without preoperative CD had similar baseline HRQOL and on average both groups experienced some HRQOL improvement. However, those with preoperative CPSM had significantly worse postoperative ODI, PCS, SRS-22 Activity, SRS-22 Appearance, SRS-22 Pain, SRS-22 Satisfaction, and SRS-22 Total score, and were less likely to meet MCID for ODI, PCS, SRS-22 Activity, and SRS-22 Pain scores with the following ORs and 95% CIs: ODI 0.19 (0.07-0.58), PCS 0.17 (0.06-0.47), SRS-22 Activity 0.23 (0.09-0.62), SRS-22 Pain 0.20 (0.08-0.53), and SRS-22 Appearance 0.34 (0.12-0.94). Preoperative CK did not have an effect on outcomes. Interestingly, despite correction of the thoracolumbar deformity, 53.3% and 51.4% of patients had persistent CPSM and persistent CK, respectively. CONCLUSIONS: Patients with thoracolumbar deformity without preoperative CD are likely to have greater improvements in HRQOL after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity.
AB - OBJECTIVE: A high prevalence of cervical deformity (CD) has been identified among adult patients with thoracolumbar spinal deformity undergoing surgical treatment. The clinical impact of this is uncertain. This study aimed to quantify the differences in patient-reported outcomes among patients with adult spinal deformity (ASD) based on presence of CD prior to treatment. METHODS: A retrospective review was conducted of a multicenter prospective database of patients with ASD who underwent surgical treatment with 2-year follow-up. Patients were grouped by the presence of preoperative CD: 1) cervical positive sagittal malalignment (CPSM) C2-7 sagittal vertical axis ≥ 4 cm; 2) cervical kyphosis (CK) C2-7 angle > 0; 3) CPSM and CK (BOTH); and 4) no baseline CD (NONE). Health-related quality of life (HRQOL) scores included the Physical Component Summary and Mental Component Summary (PCS and MCS) scores of the 36-Item Short Form Health Survey (SF-36), Oswestry Disability Index (ODI), Scoliosis Research Society-22 questionnaire (SRS-22), and minimum clinically important difference (MCID) of these scores at 2 years. Standard radiographic measurements were conducted for cervical, thoracic, and thoracolumbar parameters. RESULTS: One hundred eighty-two patients were included in this study: CPSM, 45; CK, 37; BOTH, 16; and NONE, 84. Patients with preoperative CD and those without had similar baseline thoracolumbar radiographic measurements and similar correction rates at 2 years. Patients with and without preoperative CD had similar baseline HRQOL and on average both groups experienced some HRQOL improvement. However, those with preoperative CPSM had significantly worse postoperative ODI, PCS, SRS-22 Activity, SRS-22 Appearance, SRS-22 Pain, SRS-22 Satisfaction, and SRS-22 Total score, and were less likely to meet MCID for ODI, PCS, SRS-22 Activity, and SRS-22 Pain scores with the following ORs and 95% CIs: ODI 0.19 (0.07-0.58), PCS 0.17 (0.06-0.47), SRS-22 Activity 0.23 (0.09-0.62), SRS-22 Pain 0.20 (0.08-0.53), and SRS-22 Appearance 0.34 (0.12-0.94). Preoperative CK did not have an effect on outcomes. Interestingly, despite correction of the thoracolumbar deformity, 53.3% and 51.4% of patients had persistent CPSM and persistent CK, respectively. CONCLUSIONS: Patients with thoracolumbar deformity without preoperative CD are likely to have greater improvements in HRQOL after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity.
KW - Adult spinal deformity
KW - Cervical deformity
KW - Cervical sagittal alignment
KW - Cervical sagittal vertical axis
KW - Health-related quality of life
KW - Minimum clinically important difference
UR - http://www.scopus.com/inward/record.url?scp=84974784751&partnerID=8YFLogxK
U2 - 10.3171/2015.3.SPINE141098
DO - 10.3171/2015.3.SPINE141098
M3 - Article
C2 - 26360147
AN - SCOPUS:84974784751
SN - 1547-5654
VL - 24
SP - 108
EP - 115
JO - Journal of Neurosurgery: Spine
JF - Journal of Neurosurgery: Spine
IS - 1
ER -