RESUMO
STUDY DESIGN: Retrospective descriptive, multicenter study. OBJECTIVE: The aim of this study was to predict the three-dimensional (3D) radiographic outcomes of the spinal surgery in a cohort of adolescent idiopathic scoliosis (AIS) as a function preoperative spinal parameters and surgeon modifiable factors. SUMMARY OF BACKGROUND DATA: Current guidelines for posterior spinal fusion surgery (PSF) in AIS patients are based on two-dimensional classification of the spinal curves. Despite the high success rate, the prediction of the 3D spinal alignment at the follow-ups remains inconclusive. A data-driven surgical decision-making method that determines the combination of the surgical procedures and preoperative patient specific parameters that leads to a specific 3D global spinal alignment outcomes at the follow-ups can lessen the burden of surgical planning and improve patient satisfaction by setting expectations prior to surgery. METHODS: A dataset of 371 AIS patients who underwent a PSF with two-year follow-up were included. Demographics, 2D radiographic spinal and pelvic measurements, clinical measurements of the trunk shape, and the surgical procedures were collected prospectively. A previously developed classification of the preoperative global 3D spinal alignment was used as an additional predictor. The 3D spinal alignment (vertebral positions and rotations) at two-year follow-up was used as the predicted outcome. An ensemble learner was used to predict the 3D spinal alignment at two-year follow-up as a function of the preoperative parameters with and without considering the surgeon modifiable factors. RESULTS: The preoperative and surgical factors predicted three clusters of 3D surgical outcomes with an accuracy of 75%. The prediction accuracy decreased to 64% when only preoperative factors, without the surgical factors, were used in the model. Predictor importance analysis determined that preoperative distal junctional kyphosis, pelvic sagittal parameters, end-instrumented vertebra (EIV) angulation and translation, and the preoperative 3D clusters are the most important patient-specific predictors of the outcomes. Three surgical factors, upper and lower instrumented vertebrae, and the operating surgeon, were important surgical predictors. The role of surgeon in achieving a certain outcome clusters for specific ranges of preoperative T10-L2 kyphosis, EIV angulation and translation, thoracic and lumbar flexibilities, and patient's height was significant. CONCLUSION: Both preoperative patient-specific and surgeon modifiable parameters predicted the 3D global spinal alignment at two-year post PSF. Surgeon was determined as a predictor of the outcomes despite including 20 factors in the analysis that described the surgical moves. Methods to quantify the differences between the implemented surgeon modifiable factors are essential to improve outcome prediction in AIS spinal surgery.Level of Evidence: 3.
Assuntos
Imageamento Tridimensional/tendências , Aprendizado de Máquina/tendências , Satisfação do Paciente , Escoliose/diagnóstico por imagem , Escoliose/cirurgia , Cirurgiões/tendências , Adolescente , Estudos de Coortes , Feminino , Humanos , Imageamento Tridimensional/métodos , Masculino , Prognóstico , Estudos Retrospectivos , Fusão Vertebral/métodos , Fusão Vertebral/tendências , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/cirurgia , Resultado do TratamentoRESUMO
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy. SUMMARY OF BACKGROUND DATA: Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF. METHODS: Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain. RESULTS: Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; Pâ=â0.046). Postoperatively, all cohorts experienced significant (Pâ<â0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (Pâ=â0.011), RR (Pâ=â0.006), and % minimum clinically important difference (Pâ=â0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (Pâ=â0.025). CONCLUSION: Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements. LEVEL OF EVIDENCE: 3.
Assuntos
Vértebras Cervicais/cirurgia , Discotomia/tendências , Cervicalgia/cirurgia , Radiculopatia/cirurgia , Doenças da Medula Espinal/cirurgia , Fusão Vertebral/tendências , Adulto , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cervicalgia/diagnóstico , Cervicalgia/etiologia , Medição da Dor/métodos , Medição da Dor/tendências , Radiculopatia/complicações , Radiculopatia/diagnóstico , Estudos Retrospectivos , Doenças da Medula Espinal/complicações , Doenças da Medula Espinal/diagnóstico , Resultado do TratamentoRESUMO
STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of the present study is to determine how body mass index (BMI) affects patient-reported outcome measurements (PROMs) after lumbar fusions. SUMMARY OF BACKGROUND DATA: Although greater preoperative BMI is known to increase the rates of adverse events after surgery, there is a paucity of literature assessing the influence of BMI on PROMs after lumbar fusion. METHODS: Patients undergoing lumbar fusion surgery between 1 and 3 levels were retrospectively identified. PROMs analyzed were the Short Form-12 Physical Component Score, Mental Component Score, Oswestry Disability Index (ODI), and Visual Analog Scale Back and Leg pain scores. Patients were divided into groups based on preoperative BMI: class 1, BMI <25.0; class 2, BMI 25.0 to 29.9; class 3, BMI 30.0 to 34.9; and class 4, BMI ≥35.0. Absolute PROM scores, the recovery ratio, and the percentage of patients achieving minimum clinically important difference between groups were compared. RESULTS: A total of 54 (14.8%) patients in class 1, 140 (38.2%) in class 2, 109 (29.8%) in class 3, and 63 (17.2%) in class 4 were included. All patients improved after surgery across all outcome measures (Pâ<â0.001) except for class 4 patients, who did not improve in terms of Short Form-12 Mental Component Score scores after surgery (Pâ=â0.276). Preoperative Short Form-12 Physical Component Score (Pâ=â0.002) and Oswestry Disability Index (Pâ<â0.0001) scores were significantly different between BMI groups-with class 4 having worse disability than class 1 and 2. BMI was not a significant predictor for any outcome domain. Overall 30- and 90-day readmission rates were similar between groups, with a higher revision rate in the class 4 group (Pâ=â0.036), due to a higher incidence of postoperative surgical site infections (Pâ=â0.014). CONCLUSION: All patients undergoing short-segment lumbar fusion for degenerative disease improved to a similar degree with respect to PROMs. Those in the highest class of obesity (BMI ≥35.0) were, however, at a greater risk for postoperative surgical site infection. LEVEL OF EVIDENCE: 3.
Assuntos
Índice de Massa Corporal , Vértebras Lombares/cirurgia , Obesidade/cirurgia , Medidas de Resultados Relatados pelo Paciente , Fusão Vertebral/tendências , Infecção da Ferida Cirúrgica/etiologia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico por imagem , Medição da Dor/métodos , Estudos Retrospectivos , Fusão Vertebral/métodos , Infecção da Ferida Cirúrgica/diagnóstico por imagem , Resultado do TratamentoRESUMO
STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: The aim of this study was to determine the differences in the sagittal spinopelvic parameters between the nonscoliotic controls, preoperative, and different time points postoperative in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The postoperative changes in the sagittal profile of Lenke 1 and 5 AIS at varying time points after posterior spinal fusion (PSF) has not been rigorously demonstrated; studies performed have had conflicting results. METHODS: Sagittal spinal and pelvic parameters, T5-T12 thoracic kyphosis (TK), L1-S1 lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and sagittal vertical axis (SVA), for Lenke 1 and 5 preoperatively, at immediate, less than 2-year, and more than 2-year postoperatively, and for nonscoliotic adolescents were searched. Differences in the sagittal spinopelvic parameters between preoperative and the follow-ups and between the nonscoliotic and pre- and postoperative AIS subtypes were calculated through meta-analysis. RESULTS: A total of 22 studies on Lenke1 (1229 patients), 13 studies on Lenke5 (437 patients), and 18 studies on controls (1636 patients) were reviewed. Among all the measured variables, only PI in Lenke1 was significantly different between the final follow-up and controls, Pâ<â0.05. In Lenke 1, SVA was significantly more anterior at the immediate postoperative than preoperative, but continued moving posteriorly up to 2-year postoperative resulting in no significant difference in the SVA position between the final follow-up and preoperative, Pâ>â0.05. In Lenke 5, SVA was significantly more posterior at the immediate postoperative and more anterior at the final follow-up than the preoperative measurements, pâ<â0.05. CONCLUSIONS: Continuous changes in the sagittal spinal parameters should be expected after PSF. Normalization of the sagittal spinal parameters appears to be the rule after PSF, and watchful waiting appears to be appropriate in this population when viewing the lateral X-ray postoperatively. LEVEL OF EVIDENCE: 4.
Assuntos
Ossos Pélvicos/cirurgia , Sacro/cirurgia , Escoliose/cirurgia , Fusão Vertebral/métodos , Adolescente , Criança , Feminino , Seguimentos , Humanos , Cifose/diagnóstico por imagem , Cifose/cirurgia , Lordose/diagnóstico por imagem , Lordose/cirurgia , Masculino , Ossos Pélvicos/diagnóstico por imagem , Período Pós-Operatório , Estudos Retrospectivos , Sacro/diagnóstico por imagem , Escoliose/diagnóstico por imagem , Fusão Vertebral/tendências , Adulto JovemRESUMO
STUDY DESIGN: A retrospective review of prospectively collected data. OBJECTIVE: Compare health-related quality of life (HRQOL) outcome metrics in patients undergoing primary and revision anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: ACDF is associated with significant improvements in HRQOL outcome metrics. However, 2.9% of patients per year will develop symptomatic adjacent segment disease and there is a paucity of literature on HRQOL outcomes after revision ACDF. METHODS: Patients were identified who underwent either a primary or revision ACDF, and who had both preoperative and a minimum of 1-year postoperative HRQOL outcome data. Pre- and postoperative Short Form 12 Physical Component Score (SF12 PCS), Short Form 12 Mental Component Score (SF12 MCS) Visual Analog Scale for neck pain (VAS-Neck), VAS-Arm, and Neck Disability Index (NDI) scores were compared. RESULTS: A total of 360 patients (299 primary, 61 revision) were identified. Significant improvement in SF12 PCS, NDI, VAS-Neck, and VAS-Arm was seen in both groups; however, only a significant improvement in SF12 MCS was seen in the primary group. When comparing the results of a primary versus a revision surgery, the SF12 PCS score was the only outcome with a significantly different net improvement in the primary group (7.23â±â9.72) compared to the revision group (2.9â±â11.07; Pâ=â0.006) despite similar baseline SF12 PCS scores. The improvement in each of the other reported HRQOL outcomes did not significantly vary between surgical groups. CONCLUSION: A revision ACDF for cervical radiculopathy or myelopathy leads to a significant improvement in the HRQOL outcome, and with the exception of the SF12 PCS, these results are similar to those of patients undergoing a primary ACDF. LEVEL OF EVIDENCE: 2.
Assuntos
Vértebras Cervicais/cirurgia , Discotomia/psicologia , Qualidade de Vida/psicologia , Reoperação/psicologia , Fusão Vertebral/psicologia , Adulto , Discotomia/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reoperação/tendências , Estudos Retrospectivos , Fusão Vertebral/tendências , Resultado do TratamentoRESUMO
STUDY DESIGN: This study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict postoperative neurological deficits after posterior cervical fusions (PCF). Eight hundred forty six eligible patients underwent PCF at the University of Pittsburgh Medical Center (UPMC), from 2010 to 2012. OBJECTIVE: To assess the specificity and sensitivity of intraoperative monitoring in predicting postoperative neurological deficits during PCF. SUMMARY OF BACKGROUND DATA: We calculated the predictive value, including sensitivity and specificity, of changes in SSEPs to identify neurological deficits postoperatively. We used a receiver operating characteristic (ROC) curve with SSEP categories as cutoff values to further evaluate the diagnostic accuracy of change in SSEPs and postoperative neurological deficit. METHODS: All patients had preposition baselines and continuous SSEP monitoring throughout the surgery. Statistical analysis was completed using SPSS version 22 (IBM Corp., Armonk, NY). RESULTS: Age and sex did not influence outcomes. Obesity affected patient outcome. The SSEP categories of significant changes and loss of responses resulted in a sensitivity/specificity of 0.30/0.96 and 0.16/0.98, respectively. The receiver operating characteristic curve has an area under the curve for significant change in/loss of SSEPs of 0.62/0.65 with a 95% confidence interval of 0.525 to 0.714/0.509 to 0.797. CONCLUSION: Significant SSEP changes during PCF are a very specific but poorly sensitive indicator of postoperative neurological deficits. The odds ratio for significant changes in SSEPs and loss of waveforms was 9.80 and 11.82, respectively, with a 95% confidence interval of 4.695 to 20.46 and 4.45 to 31.41, respectively. LEVEL OF EVIDENCE: 1.
Assuntos
Vértebras Cervicais/cirurgia , Potenciais Somatossensoriais Evocados/fisiologia , Monitorização Intraoperatória/normas , Doenças do Sistema Nervoso/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Fusão Vertebral/efeitos adversos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Doenças da Medula Espinal/epidemiologia , Doenças da Medula Espinal/fisiopatologia , Doenças da Medula Espinal/cirurgia , Fusão Vertebral/tendênciasRESUMO
STUDY DESIGN: Retrospective review. OBJECTIVE: (1) To describe change in treatment patterns for degenerative spondylolisthesis (DS). (2) To report regional variation in treatment of DS. (3) To describe variation in surgeon-reported outcomes for DS based on treatment. SUMMARY OF BACKGROUND DATA: Spinal stenosis associated with DS is commonly treated with decompression and fusion but little is known about the optimal fusion technique. During a 6-month period, American Board of Orthopaedic Surgery step II candidates submit procedure lists; these lists have been stored in an electronic database since 1999. METHODS: The American Board of Orthopaedic Surgery database was retrospectively queried to identify patients who underwent surgery for DS from 1999 to 2011. Included patients underwent uninstrumented fusion, fusion with posterior instrumentation, fusion using interbody device, or decompression without fusion. Utilization of these procedures was analyzed by year and geographic region. RESULTS: The study period included 5639 cases; the annual number of cases doubled during the study period. The percentage of cases treated with interbody fusion (IF) increased significantly throughout the study period, from 13.6% (1999-2001) to 32% (2009-2011) (P<0.001). The percentage of DS cases treated with posterolateral fusion peaked in 2003 then decreased as the rate of IF increased. In 2011, the rates of posterolateral fusion (40%) and posterolateral fusion with IF (37%) were nearly identical. The Northwest had the highest rate of IF (41%), >10% higher than any other region (P<0.001) and more than 23% higher than the Southeast (P<0.001). CONCLUSION: Despite little evidence guiding treatment strategy for DS, national treatment patterns have changed dramatically during the past 13 years. The rapid adoption of IF and substantial regional variation in treatment utilization patterns raises questions about drivers of change including perceptions about associated fusion rates, the importance of sagittal balance and differential reimbursement. LEVEL OF EVIDENCE: 4.
Assuntos
Vértebras Lombares/cirurgia , Fusão Vertebral/tendências , Espondilolistese/cirurgia , Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/estatística & dados numéricos , Descompressão Cirúrgica/tendências , Humanos , Fixadores Internos/estatística & dados numéricos , Ortopedia/estatística & dados numéricos , Ortopedia/tendências , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Fusão Vertebral/estatística & dados numéricos , Estenose Espinal/cirurgia , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Fifty-one patients with cervical spondylotic myelopathy (CSM) treated by anterior cervical corpectomy with fusion (ACWF) at our institution were included in a study during a period of 10 years to evaluate neurological, anatomical, and functional outcomes including satisfaction levels. METHODS: We have completed a prospective evaluation of 39 patients with spondylotic myelopathy submitted to ACWF during the period of 1989-2000. The data were analyzed for age, duration of symptoms, severity of preoperative neurological deficit, and single-level or multilevel compressive status looking for possible association with prognostic surrogate data and clinical outcome that were evaluated with the Nurick score and a survey of level of satisfaction. RESULTS: Of the 51 patients, 39 fullfilled the intended follow-up being 28 men (71.8%) and 11 women (28.2%). The average age was 63.5 years. Duration of symptoms ranged from 1 to 240 months (mean, 38.1 months). The mean preoperative Nurick scale score was 2.97; the mean postoperative score was 2.1. The most frequently involved vertebral body was C5 (71.7%). The follow-up period was longer than 18 months for all patients. Postoperative nonneurological complications occurred in 8 patients (15.6%). The mortality rate was 1.9% (n = 1). Postoperative results showed improvement in 25 patients (64.1%), no change in 13 (33.3%), and worsening in 1 (2.6%). The correlation coefficient of preoperative and postoperative Nurick scores was 0.733 (R(2) = 0.53). Of the 39 patients, 31 answered the questionnaire for quality of life-19 (61.2%) were very satisfied, 6 were satisfied (19.35%), and 6 were not satisfied (19.35%). CONCLUSION: Most patients (80.6%) were very satisfied or satisfied with the outcome and would decide again for the surgery (87%) if the results were previously known. Anterior cervical corpectomy with fusion was a reliable and rewarding procedure for CSM, with functional improvement in most patients. Excellent long-term outcome results in cervical fusion can be achieved without the use of hardware instrumentation.