The Effect of Discharging Patients with Low Hemoglobin Levels on Hospital Readmission and Quality of Life after Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort. PURPOSE: This study aims to evaluate the impact of anemia on functional outcomes, health-related quality of life (HRQoL), and early hospital readmission (EHR) rates after adult spinal deformity (ASD) surgery at the time of discharge from the hospital. OVERVIEW OF LITERATURE: Concerns with risks of transfusion, insufficient evidence for its benefits, and the possibility of associated adverse outcomes have led to restrictive transfusion practices. Therefore, patients are discharged according to patient blood management programs that are implemented in hospitals nationwide to reduce unnecessary blood transfusions. However, not many comprehensive kinds of studies exist on the effect of postoperative anemia on functional life and complications. METHODS: Anemia severity was defined following the 2011 World Health Organization guidelines. All patients had HRQoL tests as well as complete blood counts pre- and postoperatively. EHR is the admission within 30 days of discharge and was used as the dependent parameter. RESULTS: This study comprised 225 surgically treated ASD patients with a median age of 62.0 years, predominantly women (80%). Of the 225 patients, 82, 137, and six had mild, moderate, and severe anemia at the time of discharge, respectively. Seventeen of the patients (mild [11, 64.7%]; moderate [5, 29.4%]; severe [1, 5.9%]) were readmitted within 30 days. The mean hemoglobin values were higher in readmitted patients (p=0.071). Infection was the leading cause of readmission (n=12), but a low hemoglobin level was not observed in any of these patients at the time of discharge. Except for Scoliosis Research Society-22 questionnaire, HRQoL improvements did not reach statistical significance in early readmitted patients in the first year after surgery. CONCLUSIONS: The results of this study demonstrated that the occurrence and the severity of postoperative anemia are not associated with EHR in surgically treated patients with ASD. The findings of the current research suggested that clinical awareness of the parameters other than postoperative anemia may be crucial. Thus, improvements in HRQoL scores were poor in early readmitted patients 1 year after surgery.

Relative pelvic version displays persistent compensatory measures with normalised sagittal vertical axis after deformity correction.

PURPOSE: A normal sagittal vertical axis (SVA) after spinal deformity correction can yield mechanical complications of up to 30%. Post-operative compensatory pelvic orientation can produce a normal SVA. We assess relative pelvic version (RPV), an individualised measure, for persistent post-operative compensatory measures. METHODS: Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA (< ± 50 mm) at 6-week follow-up were included, who were then followed-up after 2 years. These only included patients with fusion of > 4 vertebrae extending to L5 or below. Six-week subgroups were made regarding pelvis orientation, relative pelvic version (RPV: anteversion, aligned, moderate or severe retroversion) with analysis of patient-related outcome measures (PROMs), complications and spino-pelvic sagittal parameters. RESULTS: At 6 weeks, 140 patients met the inclusion criteria, 5 (3.6%) patients had anteversion, 59 (42.1%) were aligned, 60 (42.9%) had moderate retroversion and 16 (11.4%) patients had severe retroversion. Follow-up after 2 years demonstrated increased RPV in all groups except the severe RPV group who were more likely to develop SVA > 50 mm. Complications occurred in all groups. Significant 2-year differences were observed between moderate and severe RPV for back pain and PROMs but not between other RPV groups. CONCLUSION: Adult spinal deformity patients with a normal SVA after spino-pelvic instrumentation carry a significant risk of retroversion progression post-operatively, followed by increased positive sagittal balance. Relative pelvic version (RPV) measurements when categorised into anteversion, aligned, moderate retroversion and severe retroversion at 6 weeks were predictive of PROMs at 2 years.

Minimum clinically important difference of the health-related quality of life scales in adult spinal deformity calculated by latent class analysis: is it appropriate to use the same values for surgical and nonsurgical patients?

BACKGROUND CONTEXT: Health-related quality of life (HRQOL) parameters have been shown to be reliable and valid in patients with adult spinal deformity (ASD). Minimum clinically important difference (MCID) has become increasingly important to clinicians in evaluating patients with a threshold of improvement that is clinically relevant. PURPOSE: To calculate MCID and minimum detectable change (MDC) values of total scores of the Core Outcome Measures Index (COMI), Oswestry Disability Index (ODI), Physical Component Summary (PCS), Mental Component Summary (MCS) of the Short Form 36 (SF-36), and Scoliosis Research Society 22R (SRS-22R) in surgically and nonsurgically treated ASD patients who have completed an anchor question at pretreatment and 1-year follow-up. STUDY DESIGN/SETTING: Prospective cohort. PATIENT SAMPLE: Surgical and nonsurgical patients from a multicenter ASD database. OUTCOME MEASURES: Self-reported HRQOL measures (COMI, ODI, SF-36, SRS-22R, and anchor question). METHODS: A total of 185 surgical and 86 nonsurgical patients from a multicenter ASD database who completed pretreatment and 1-year follow-up HRQOL scales and the anchor question at the first year follow-up were included. The anchor question was used to determine MCID for each HRQOL measure. MCIDs were calculated by an anchor-based method using latent class analysis (LCA) and MDCs by a distribution-based method. RESULTS: All differences between means of baseline and first year postoperative total score measures for all scales demonstrated statistically significant improvements in the overall population as well as the surgically treated patients but not in the nonsurgical group. The calculated MDC and MCID values of HRQOL parameters in the entire study population were 1.34 and 2.62 for COMI, 10.65 and 14.31 for ODI, 6.09 and 7.33 for SF-36 PCS, 6.14 and 4.37 for SF-36 MCS, and 0.42 and 0.71 for SRS-22R. The calculated MCID values for surgical and non-surgical treatment groups were 2.76 versus 1.20 for COMI, 14.96 versus 2.45 for ODI, 7.83 versus 2.15 for SF-36 PCS, 5.14 versus 2.03 for SF-36 MCS, and 0.94 versus 0.11 for SRS-22R; the MDC values for surgical and nonsurgical treatment groups were 1.22 versus 1.51 for COMI, 10.27 versus 9.45 for ODI, 5.16 versus 6.77 for SF-36 PCS, 6.05 versus 5.67 for SF-36 MCS, and 0.38 versus 0.43 for SRS-22R. CONCLUSIONS: This study has demonstrated that MCID calculations for the HRQOL scales in ASD using LCA yield values comparable to other studies that had used different methodologies. The most important finding was the significantly different MCIDs for COMI, ODI, SF-36 PCS and SRS-22 in the surgically and nonsurgically treated cohorts. This finding suggests that a universal MCID value, inherent to a specific HRQOL for an entire cohort of ASD may not exist. Use of different MCIDs for surgical and nonsurgical patients may be warranted.

The Influence of Diagnosis, Age, and Gender on Surgical Outcomes in Patients With Adult Spinal Deformity.

STUDY DESIGN: Retrospective review of prospectively collected data from a multicentric database. OBJECTIVES: To determine the clinical impact of diagnosis, age, and gender on treatment outcomes in surgically treated adult spinal deformity (ASD) patients. METHODS: A total of 199 surgical patients with a minimum follow-up of 1 year were included and analyzed for baseline characteristics. Patients were separated into 2 groups based on improvement in health-related quality of life (HRQOL) parameters by minimum clinically important difference. Statistics were used to analyze the effect of diagnosis, age, and gender on outcome measurements followed by a multivariate binary logistic regression model for these results with statistical significance. RESULTS: Age was found to affect SF-36 PCS (Short From-36 Physical Component Summary) score significantly, with an odds ratio of 1.017 (unit by unit) of improving SF-36 PCS score on multivariate analysis (P < .05). The breaking point in age for this effect was 37.5 years (AUC = 58.0, P = .05). A diagnosis of idiopathic deformity would increase the probability of improvement in Oswestry Disability Index (ODI) by a factor of 0.219 and in SF-36 PCS by 0.581 times (P < .05). Gender was found not to have a significant effect on any of the HRQOL scores. CONCLUSIONS: Age, along with a diagnosis of degenerative deformity, may have positive effects on the likelihood of improvement in SF-36 PCS (for age) and ODI (for diagnosis) in surgically treated patients with ASD and the breaking point of this effect may be earlier than generally anticipated. Gender does not seem to affect results. These may be important in patient counseling for the anticipated outcomes of surgery.

Radiographic Outcome Differences in Distraction-Based Growing Rod Constructs Using Tandem Versus Wedding Band Connectors.

STUDY DESIGN: Comparative cohort study. OBJECTIVE: To compare coronal deformity control, lengthening efficacy, and sagittal alignment between distraction-based growing rod constructs utilizing tandem versus wedding band connectors. SUMMARY OF BACKGROUND DATA: Different construct designs exist for growing rod treatment of early-onset scoliosis. All use a version of a rod connector, with the two main types being tandem and wedding band. Little data exist to quantify the impact of connector choice on radiographic outcomes of treatment. METHODS: A multicenter database of prospectively and retrospectively collected data on early-onset scoliosis patients was reviewed. Patients of any thoracic or thoracolumbar coronal plane deformity whose initial growing rod treatment was initiated before age 10 years and underwent at least 3 years of dual growing rod treatment with either tandem or wedding band connectors were included. Preoperative, immediate postoperative, and prefinal radiographs were reviewed and compared in regard to major curve magnitude, T1-T12 and T1-S1 spinal length, length of instrumentation, and sagittal plane measures. RESULTS: A total of 209 patients were included. The overall percent change from preoperative to prefinal in all radiographic parameters was not different between the two groups indicating similar efficacy in treatment. After controlling for institutional variation, the improvement of the major coronal Cobb angle from preoperative to prefinal was statistically improved for the tandem group (34° vs. 29°, p = .002) and the difference in T5-T12 kyphosis from preoperative to prefinal was significantly different between the groups (-6° vs. +1.3°, p = .008). CONCLUSION: We identified little difference in the effects of connector type on radiographic outcomes of patients treated with traditional growing rod, which indicates that both wedding band and tandem connectors function similarly. The small differences detected suggest that tandem connectors may improve major Cobb correction, and wedding band connectors may maintain thoracic kyphosis over time. LEVEL OF EVIDENCE: Level III.

NRS20: Combined Back and Leg Pain Score: A Simple and Effective Assessment of Adult Spinal Deformity.

STUDY DESIGN: Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE: To evaluate back and leg pain as a combined score in ASD and compare their relative and cumulative correlations with health-related quality of life (HRQOL) and sagittal parameters. SUMMARY OF BACKGROUND DATA: Pain and disability are commonly reported in patients with ASD. This can affect their back, their legs or both. ASD-associated pain has been correlated with numerous HRQOL scores and radiological parameters. METHODS: Preoperative pain intensity was assessed with a Numerical Rating Scale (NRS) for individual back and leg pain as well as a combined score, NRS20 (0-20, back plus leg pain).This yielded a range of static measures in all patients with ASD with differing burdens of disease. Linear regression analysis was performed to calculate the correlation between pain and HRQOL scores (Scoliosis Research Society 22, 36-Item Short Form Health Survey Physical Component Summary, 36-Item Short Form Health Survey Mental Component Summary, Core Outcome Measures Index, and Oswestry Disability Index), and radiological spinopelvic parameters (sagittal and coronal planes). RESULTS: A total of 1309 patients were included in this study. A combined score (NRS20) was better correlated with HRQOL (P < 0.01 for all) and sagittal parameters (P < 0.01 for all) than individual back or leg pain scores. Evaluation of the relative contributions of back and leg pain demonstrate a higher correlation with HRQOL scores for back pain and a higher correlation with sagittal parameters for leg pain. The distribution of NRS20 pain scores demonstrated three clear patterns of pain: back pain only, moderate back pain with varying mild-moderate leg pain, and severe equivalent back and leg pain. Similar values were noted for nonoperative and operative patients. CONCLUSION: The distribution and intensity of pain and its correlations with clinical and radiological parameters provide insight into the pathogenesis of ASD. A combined score has a simple yet valuable contribution to the assessment of symptoms in ASD. LEVEL OF EVIDENCE: 3.

Adult spinal deformity: a very heterogeneous population of patients with different needs.

OBJECTIVE: The purpose of this study was to analyze and demonstrate the heterogeneity in adult spinal deformity (ASD) populations by baseline health-related quality of life (HRQL) data. METHODS: ASD was defined as patients over 18 years of age with any of the following: coronal deformity >20°, sagittal vertical axis (SVA) >5 cm, pelvic tilt >25°, or thoracic kyphosis >60°. Three hundred fifty-two patients meeting the above definition of ASD were analyzed for measures of HRQL (Oswestry disability index [ODI], SRS-22 [Scoliosis Research Society-22], and SF-36 [Short form-36 health survey] questionnaires) at presentation. Age groups were defined as 18-40, 40-60, and >60 years. Deformity was analyzed as either degenerative (DS) or idiopathic (IS) (294 patients; 71 degenerative, 223 idiopathic). RESULTS: There were significant differences between age groups--predominantly between the lower age group (18-40) and others--for all HRQL parameters except SRS-22 mental health and SF-36 mental component score. Similarly, HRQL measures for DS and IS deformities were significantly different. Regarding location of main curves, thoracolumbar/lumbar (TL/L) (70.2%) was dominant for the DS group and thoracic (55%) for the IS group. Mean age was 65 years for the DS group and 36 for the IS group, which were significantly different. Radiographic parameters were also significantly different between these groups, with IS patients having more coronal deformity and better sagittal balance. CONCLUSION: ASD patients are very heterogeneous at presentation, depending on age and diagnosis. There is a distinct need to stratify ASD as early and late presentation ASD and/or by diagnosis. Patients with IS deformity may be very different from those with DS deformity, even at time of presentation. These differences must be taken into consideration in treatment of these patients, as well as for the analysis of the results of treatment.

Is there a relationship between thoracic dimensions and pulmonary function in early-onset scoliosis?

STUDY DESIGN: Cross-sectional retrospective analysis. OBJECTIVE: To examine the degree of correlation between thoracic dimension outcome measures and pulmonary function in early-onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA: Change in thoracic dimension (TD) measurements and spine length are commonly reported outcome measures after treatment for EOS. Although ultimately improving or maintaining pulmonary function is the goal of EOS treatment strategies, it is unclear whether commonly reported 2-dimensional TD measurements represent good predictors of pulmonary function. METHODS: A cross-sectional analysis of patients including all diagnoses obtained from 2 EOS databases containing TD measurements and pulmonary function data was performed. Relationships between individual TD measurements and pulmonary function measurements were assessed using the Pearson correlation analysis. TD measurements (pelvic inlet width, T1-T12 height, T1-S1 height, and coronal chest width) and standard pulmonary function measurements were compared. TD percentiles normalized for pelvic inlet width were also calculated and correlated with pulmonary function measurement percentiles. Univariate and multivariate linear regression analyses determined whether TD measurements could predict pulmonary function. RESULTS: There were 121 patients (65 females, 56 males) in the study. Mean age at evaluation was 9.3 years (range, 2.7-18.1 yr). T1-T12 height, T1-S1 height, maximal chest width, and pelvic inlet width were all significantly correlated with forced air volume expelled in 1 second, total forced air volume, and total lung capacity (correlation coefficients [r] 0.33-0.61; all P<0.001). T1-T12 predicted percentile (normalized for pelvic width) was significantly correlated with forced air volume expelled in 1 second and total forced air volume predicted percentiles (r=0.32, P<0.001 and r=0.27, P=0.004, respectively). Regression analysis determined that T1-T12 percentile was a significant predictor of forced air volume expelled in 1 second percentile and total forced air volume percentiles. Regression analysis found no predictive factors of total lung capacity percentile. CONCLUSION: Traditional 2-dimensional TD measurements (T1-T12 height) used to measure outcomes in EOS can be used as weak predictors of pulmonary function outcome. However, better outcome measures need to be developed, such as 3-dimensional and dynamic measurements. LEVEL OF EVIDENCE: 3.

Late treatment of tuberculosis-associated kyphosis: literature review and experience from a SRS-GOP site.

INTRODUCTION: Spinal tuberculosis (TB) accounts for approximately half of all cases of musculoskeletal tuberculosis. Kyphosis is the rule in spinal tuberculosis and has potential detrimental effects on both the spinal cord and pulmonary function. Late-onset paraplegia is best avoided with the surgical correction of severe kyphosis, where at the same time anterior decompression of the cord is performed and the remnants of the tuberculosis-destroyed vertebral bodies are excised. MATERIAL AND METHODS: Review of the literature on late surgical treatment of TB-associated kyphosis; description and comparative analysis of the different surgical techniques. RESULTS: Kyphosis can be corrected either at the acute stage or at the healed late stage of tuberculous infection. In the late stage, the stiffness of the spine and chronic lung disease are additional considerations for the surgical approach and technique. Contrary to the traditional anterior transpleural approach used in the acute spinal tuberculosis infection, extrapleural approaches, either antero-lateral or direct posterior, are favored in late treatment. CONCLUSION: The correction of deformity is only feasible with three-column osteotomies, and posterior vertebral column resection (PVCR) is the treatment of choice in extreme kyphosis. The prognosis of the neurologic deficit (late paraplegia) is dependent on the extent of gliosis of the spinal cord.

Severe restrictive lung disease and vertebral surgery in a pediatric population.

The aim of this study is to describe the outcome of surgical treatment for pediatric patients with forced vital capacity (FVC) <40% and severe vertebral deformity. Few studies have examined surgical treatment in these patients, who are considered to be at a high risk because of their pulmonary disease, and in whom preoperative tracheostomy is sometimes recommended. Inclusion criteria include FVC <40%, age <19 years and diagnosis of scoliosis. The retrospective study of 24 patients with severe restrictive lung disease, who underwent spinal surgery. Variables studied were age and gender, pre- and postoperative spirometry (FVC, FEV1, FEV1/FVC), preoperative, postoperative and late use of non-invasive ventilation (BiPAP) or mechanical ventilation, associated multidisciplinary treatment, type and location of the curve, pre- and postoperative curve values, type of vertebral fusion, intra- and postoperative complications, duration of intensive care unit (ICU) stay and length of postoperative hospitalization. Mean age was 13 years (9-19) of which 13 were males and 11 females. Mean follow-up was 32 months (24-45). The etiology was neuromuscular in 17 patients and other etiologies in 7 patients. Mean preoperative FVC was 26% (13-39%). Eight patients had preoperative home BiPAP, 15 preoperative in-hospital BiPAP, and 2 preoperative mechanical ventilation. Nine patients had preoperative nutritional support. Preoperative curve value of the deformity was 88 degrees (40 degrees -129 degrees ). Nineteen patients with posterior fusion alone and 5 with anterior and posterior fusion were found. Mean duration of ICU stay was 5 days (1-21). Total postoperative hospital stay was 17 days (7-33). Ventilatory support in the immediate postoperative includes 16 patients requiring BiPAP and 2 volumetric ventilation. None of the patients required a tracheostomy. The intraoperative complications include one death due to acute heart failure; immediate postoperative, four respiratory failures (2 required ICU readmission) and one respiratory infection; and other minor complications occurred in six patients. Overall, 58% of patients had complications. Percentage of angle correction was 56%. After a follow-up of 30 months, FVC was 29% (13-50%). In conclusion, corrective scoliosis surgery in pediatric patients with severe restrictive lung disease is well tolerated, but the management of this population requires extensive experience with the vertebral surgery involved, and a multidisciplinary approach that includes pulmonologists, nutritionists and anesthesiologists. Currently, there is no indication for routine preoperative tracheostomy.