Michael Kelly, MD, MSCI

All Publications

• Conflating Disability, Frailty, and Multimorbidity in Adult Spinal Deformity Patients SPINE Kelly, M. P., Lovecchio, F. C., Klineberg, E. O., Smith, J. S., Line, B., Gum, J. L., Protopsaltis, T. S., Hamilton, D., Soroceanu, A., Eastlack, R., Nunley, P., Kebaish, K. M., Lenke, L. G., Hostin Jr, R. A., Gupta, M. C., Kim, H., Mundis, G. M., Ames, C. P., Hills, J., Shaffrey, C. I., Passias, P. G., Schwab, F. J., Lafage, V., Lafage, R., Bess, S., International Spine Study Grp 2026; 51 (5): 343-353

  Abstract

  Retrospective cohort study.To examine the degree of overlap between disability, multimorbidity, and frailty in a cohort of ASD patients.Frailty is a popular topic in spine research, as it is a reported risk factor for poor outcomes. Disability, multimorbidity, and frailty can coexist, sometimes causing or exacerbating one another. It is important to distinguish these conditions for perioperative optimization and to guide research initiatives.A multicenter registry of ASD patients was queried for baseline data regarding frailty, as measured by the Edmonton Frail Scale, disability, as measured by the Oswestry Disability Index, and multimorbidity, as measured by the Charlson comorbidity index. The relationships between these measures and both chronological and biological age (PhenoAge) were explored. Exploratory factor analysis (EFA) examined areas of overlap between these diagnoses.There were 861 patients contributing data, mostly female (68%), most undergoing primary surgery at a median age of 66 years [interquartile range (55.1-71.6)], with 6% classified as "Frail." Chronological and PhenoAge showed weak to moderate associations with disability and frailty, though PhenoAge was stronger. There was no evidence of distinct clusters, rather a continuity of condition severity. EFA found overlap between subjective and objective measures of disability, function, and frailty.Frailty was rare (6%) in this multicenter cohort of patients. Conflation of disability and frailty is a real risk due to overlap in measures of both conditions. Disability and frailty do not form discrete categories but rather exist along a continuum, underscoring the need to abandon categorical labels in favor of continuous measures for both clinical assessment and research settings.

  View details for DOI 10.1097/BRS.0000000000005508

  View details for Web of Science ID 001688704300006

  View details for PubMedID 40955702

• What Graft Should Be Used in Pediatric Posterior Spinal Fusion? Current Trends and Perspective Among Experts JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA Okonkwo, D. D., Moore-Lotridge, S. N., Schoenecker, J. G., Jain, A., Hariharan, A. R., Vorhies, J. S., Yaszay, B., Louer Jr, C. R., Harms Study Grp 2026; 14

  View details for DOI 10.1016/j.jposna.2025.100290

  View details for Web of Science ID 001660481800001

• Saving Fusion Levels in Lenke 1/2 AR Curves: Can We Stop Short of the Last Substantially Touched Vertebra (LSTV)? Spine Brown, M. W., Hariharan, A. R., Bryan, T., Feldman, D. S., Louer, C. R., Vorhies, J. S., Murphy, J. S., Bachmann, K., Cho, R. H., Gabos, P. G., Jain, A., Lonner, B. S., Miyanji, F., Samdani, A. F., Shah, S. A., Kelly, M. P., Newton, P. O., Harms Study Group 2025

  Abstract

  STUDY DESIGN: Retrospective cohort from a multicenter registry.OBJECTIVE: Characterize the variability of the last substantially touched vertebra (LSTV) in Lenke 1- and 2-AR curves and evaluate whether clinical or radiographic factors permit fusion short of the LSTV without increased adding-on risk.SUMMARY OF BACKGROUND DATA: Lenke 1 and 2A curves with an R modifier based on L4 tilt in adolescent idiopathic scoliosis (AIS) are associated with a higher risk of adding-on after posterior spinal fusion (PSF). Fusion to the LSTV may reduce this risk but often requires extending into the distal lumbar spine, compromising motion. The safety of terminating fusion proximal to the LSTV in select patients, without increasing adding-on risk, remains uncertain.METHODS: Patients with Lenke 1- or 2-AR curves undergoing PSF with minimum 2-year follow-up were identified. Radiographs were reviewed to determine LSTV level and assess for adding-on. Patients were stratified based on whether the lowest instrumented vertebra (LIV) was proximal to or at the level of/distal to the LSTV. Among those fused proximal, univariate and multivariate analyses were used to identify protective factors. Subgroup analyses were performed by LSTV level.RESULTS: Of 324 patients, 144 (44.4%) were instrumented proximal to the LSTV. Adding-on occurred in 16.0% of all patients, more frequently in short fusions (21.5% vs. 11.7%, P=0.016). Multivariate analysis identified higher Risser (OR=1.62, P=0.006) and greater main thoracic correction (OR=1.09, P<0.001) as protective. Adding-on was rare (4.0%) when the LSTV was L4, even when fused short.CONCLUSIONS: In skeletally mature patients with adequate thoracic correction, fusion proximal to the LSTV in Lenke 1- and 2-AR curves may be performed safely. When the LSTV is L4, fusion to that level may be unnecessary, offering an opportunity for lumbar motion preservation without increased risk of adding-on.LEVEL OF EVIDENCE: IV.

  View details for DOI 10.1097/BRS.0000000000005602

  View details for PubMedID 41400008

• Knowledge translation in surgery: a scoping review of implementation strategies, effectiveness and contextual barriers and enablers. BMC health services research Manafò, E., Lugo, E., Jain, A., Petermann, L., Davies, B., Hazenbiller, O., Loomans, J. I., Taha, M. M., Schnake, K. J., Kelly, M. P., Falavigna, A., Versteeg, A., Bransford, R., Cecchinato, R., Fisher, C. 2025; 26 (1): 48

  Abstract

  Knowledge translation (KT) interventions are essential for implementing evidence-based practices in healthcare. However, despite their proven effectiveness in addressing global health challenges, KT strategies in surgery remain challenging to apply. This scoping review examines KT strategies in surgery, their effectiveness, and key barriers and enablers to their implementation.This scoping review followed the Arksey and O'Malley and Levac et al. frameworks, integrating the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) and the PRISM (Practical Robust Implementation Sustainability Model) models to evaluate the effectiveness of knowledge translation interventions in surgical practice change and associated contextual barriers and facilitators. A systematic search was conducted across MEDLINE (PubMed, OVID), CINAHL (EBSCO), and PsycINFO (ProQuest). Articles were screened using predefined selection criteria, emphasizing experimental and quasi-experimental studies. Data extraction categorized KT interventions: knowledge diffusion, dissemination, and implementation approaches.A total of 34 studies met the inclusion criteria. Most were hospital-based (88%) and focused on guideline adherence. The review identified three primary KT strategies: (i) educational materials and educational outreach, (ii) reminders and prompts, and (iii) audit and feedback systems. The most effective KT strategies used a combination of these interventions to maximize impact. Barriers included physician resistance, limited leadership support, financial constraints, and workflow disruptions, while enablers included institutional leadership, structured training programs, financial incentives, and interdisciplinary collaboration. A notable finding was the lack of standardized validation processes for adopting changes in the surgical setting, which often burdens individual surgeons and their institutions, thereby constraining both capacity and motivation for practice change.Findings suggest that layered, interdisciplinary KT strategies are the most effective for driving surgical practice change and overcoming institutional barriers. The integrated application of RE-AIM and PRISM frameworks proved valuable in assessing the interventions' sustainability and real-world effectiveness. This comprehensive analysis contributes to the growing body of knowledge on effective implementation strategies in surgical settings and provides a foundation for future practice improvement initiatives. Future research should focus on refining KT methodologies, expanding implementation frameworks, and addressing barriers to sustainability across diverse surgical settings.

  View details for DOI 10.1186/s12913-025-13369-2

  View details for PubMedID 41345614

  View details for PubMedCentralID PMC12797646

• Three-Dimensional Analysis of Disc and Vertebral Height and Their Role in Kyphosis Creation in Adolescent Idiopathic Scoliosis SPINE Oba, H., Kelly, M. P., Fletcher, N., Parent, S., Upasani, V. V., Farnsworth, C., Bartley, C. E., Yaszay, B., Shah, S. A., Miyanji, F., Newton, P. O. 2025; 50 (23): 1617-1623

  Abstract

  Retrospective.Describe three-dimensional (3D) changes after adolescent idiopathic scoliosis (AIS) reconstruction, with attention to anterior column (AC) shortening and middle column (MC) lengthening.Relative elongation of the AC, particularly the disc, is a common feature of AIS. 3D correction of deformity requires creation of thoracic kyphosis (TK).An AIS registry was queried for patients treated with posterior-only instrumented fusion, with pre/postoperative biplanar radiographs and 3D spine models. MATLAB script calculated heights of the anterior disc/vertebral body (VB) and posterior disc/VB for each segment from T1 to L5 in the plane of each disc/VB. The respective disc/VB heights were summed to calculate AC length and MC length. AC and MC lengths of the instrumented segments were compared before and after surgery using paired t tests with a Bonferroni correction ( P <0.001). Linear regression examined factors related to greater MC lengthening. The relationships between AC/MC lengths and 2D/3D TK were analyzed using Pearson correlations.Five hundred sixty-four patients met inclusion (age 15 yr, female 82%; major curve 58°; 3D TK 3°, Lenke 1 44%, Risser 3/4/5 81%). Mean number of levels fused was 11, LIV T12/L1 50%, postoperative major curve 16°, 3D TK 23°. The AC shortened and the MC lengthened at all levels from T5 to T11, whereas both lengthened at T12. From T5 to T12, AC shortened 3.4 mm ( P <0.001) and MC lengthened 4.7 mm ( P <0.001). MC lengthening >10 mm was achieved in 30 (5%) cases. Longer fusions [OR 1.7 (1.2 to 2.4)] and a greater difference between anterior VB height and posterior VB height [OR 7.1, (3.1 to 16.2)] were associated with more lengthening. Anterior shortening was strongly correlated to more 3D kyphosis creation ( r =0.7, P <0.001).3D kyphosis creation requires shortening of the AC and lengthening of the MC through the discs. After the posterior longitudinal ligament (MC) is taut, a discectomy may be required for further 3D kyphosis creation.

  View details for DOI 10.1097/BRS.0000000000005410

  View details for Web of Science ID 001613337300002

  View details for PubMedID 40443180

• General and Spine-Specific Sarcopenia in Adult Spinal Deformity: a Narrative Overview of Current Strengths and Limitations. Global spine journal Bui, T. T., Joseph, K., Yahanda, A. T., Findlay, A. R., Theologis, A. A., Yagi, M., Pizones, J., Walker, C., Lord, E., Eastlack, R. K., Pellisé, F., Osorio, J. A., Jones, K., van Hooff, M., Blakemore, L., Shah, S. A., Hu, S., de Kleuver, M., Kelly, M., Ames, C., Molina, C. A. 2025: 21925682251393636

  Abstract

  Study DesignNarrative Review.ObjectivesRecent studies have separated assessment of sarcopenia into two main categories within spine surgery: (1) general sarcopenia assessing systemic muscle degeneration and (2) spine-specific sarcopenia assessing muscle degeneration within the more localized paraspinal musculature. We sought to highlight challenges in optimizing outcomes for adult spinal deformity (ASD) patients with sarcopenia and evaluate the effectiveness of using general and spine-specific sarcopenia metrics for prognostication.MethodsWe evaluated the relationship between sarcopenia and surgical outcomes in ASD, explored methods for assessing sarcopenia, and provided recommendations for managing ASD patients with consideration of sarcopenia based on literature review. Global and spine-specific sarcopenia assessment approaches were compared, emphasizing the impact of diagnostic methods, such as MRI and clinical performance tests, on outcome prediction.ResultsThe large variability in sarcopenia measurement methods significantly affected its prognostic utility in ASD treatment. Studies using the psoas muscle to define global sarcopenia revealed mixed results for prediction. Meanwhile, assessments focusing on fatty infiltration of paraspinal muscles showed stronger correlations with complications than general sarcopenia markers.ConclusionStandardizing sarcopenia assessment in ASD is essential to facilitating its integration into clinical practice. Assessments focusing on paraspinal muscle quality demonstrated stronger associations with complications than general sarcopenia markers, underscoring the dissociation between systemic and spine-specific muscle health. Hence, future studies should refine sarcopenia metrics for spine-specific assessment as opposed to global metrics. Research should also be done to optimize interventions specifically targeting spinal sarcopenia to potentially enhance surgical outcomes. Adopting consistent, targeted sarcopenia evaluation can contribute to safer, more effective treatment pathways for ASD patients.

  View details for DOI 10.1177/21925682251393636

  View details for PubMedID 41160895

• The T4-L1-Hip Axis Objectifies the Roussouly Classification Using Continuous Measures JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Hills, J., Molina, C., Lenke, L. G., Sardar, Z. M., Le Huec, J., Hasegawa, K., Wong, H., Dennis Hey, H., Diebo, B. G., Pallotta, N. A., Kelly, M. P. 2025; 107 (15): 1717-1725

  Abstract

  The Roussouly classification is a popular system for the categorization of spinal alignment, although the categorization of continuous measures may compromise efforts toward a precision-medicine approach to sagittal alignment in spine surgery. Vertebral-pelvic angles provide continuous measures of sagittal alignment without the risk of misclassification.We performed a cross-sectional study of asymptomatic adult volunteers with normal spines (no evidence of disc degeneration or scoliosis). Full-spine radiographs were obtained, and radiographic parameters were collected, including pelvic incidence (PI), sacral slope, lumbar lordosis, the apex of lordosis, the L1-pelvic angle (L1PA), and the T4-pelvic angle (T4PA). All spines were classified as Roussouly Type 1, 2, 3, or 4 on the basis of sacral slope and the apex of lumbar lordosis. Associations between the L1PA and PI, the L1PA and T4PA, and the T4-L1PA mismatch and PI were assessed for the whole cohort and when stratified by Roussouly type. A multinomial logistic regression model was fit to estimate Roussouly type based on PI, the L1PA, and the T4PA. Agreement (weighted κ), accuracy, and area under the receiver operating characteristic curve (1 type versus the rest) were computed. A subanalysis assessed potential variations in the relationships when Roussouly Type-3 spines were further classified as Type 3A (anteverted) versus Type 3.The 320 included volunteers had a median age of 37 years (interquartile range [IQR], 27 to 47 years), and 193 (60%) were female. By self-reported race or ethnicity, the highest percentage of patients were Caucasian (White, 38%) or East Asian (36%), followed by Arabo-Bèrbère (16%). Spines were classified as Roussouly Type 1 in 18 (6%) of the volunteers, as Type 2 in 63 (20%), as Type 3 in 161 (50%), and as Type 4 in 78 (24%). The L1PA was strongly associated with PI across Roussouly types (weakest in Roussouly Type-1 spines). A multinomial logistic regression model estimating Roussouly type by PI, the L1PA, and the T4PA showed strong agreement (weighted κ, 0.84), excellent discrimination, and overall accuracy of 0.82.The T4-L1-Hip axis is conceptually aligned with the description of spinal shapes in the Roussouly classification but with the advantage of utilizing continuous measures of spinal alignment. Goals of surgical realignment incorporating the T4-L1-Hip axis will be comparable with alignment planning using the Roussouly classification but with improved accuracy and precision.Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.24.01489

  View details for Web of Science ID 001544631100001

  View details for PubMedID 40560977

• Alignment Goals in Adult Spinal Deformity Surgery. Global spine journal Pizones, J., Hills, J., Kelly, M. P., Alavi, F., Nuñez-Pereira, S., Smith, J. S., Sardar, Z. M., Lenke, L. G., Lewis, S. J., Pellisé, F. 2025; 15 (3_suppl): 108S-122S

  Abstract

  Study DesignNarrative review.ObjectivesAdult spinal deformity (ASD) surgery has progressively transitioned from mean regional alignment targets to individualized segmental alignment goals, and from health-related quality of life (HRQL) alignment goals to the prevention of mechanical complications.MethodsNarrative review discussing sagittal alignment concepts and goals in ASD surgery.ResultsTraditional metrics for measuring sagittal spinal alignment such as pelvic incidence - lumbar lordosis (PI-LL), thoracic kyphosis, and sagittal vertical axis (SVA) may lack the specificity necessary for individualized alignment planning. Compensatory pelvic retroversion and knee flexion are critical determinants of maintaining the upright position. Research has been conflicting as to whether postoperative sagittal alignment is associated with improvements in HRQOL's. However, this may reflect a lack of sensitivity in the traditional alignment targets and PROM's measures, rather than a true lack of relationship between sagittal alignment and functional outcomes. Recent studies show that sagittal parameters have a limited impact on HRQL scores in non-operated patients, but significantly impact post-operative HRQOL measures and mechanical complications in patients treated with spinal fusion. Latest evidence suggests that compensatory mechanisms need to be eliminated and the ideal shape needs to be restored with surgery, to reduce postoperative mechanical complications. Multiple alignment strategies are proposed for that purpose.ConclusionsWhile best evidence shows an improvement in ASD alignment strategies over the last decade, mechanical failures and reoperations are still a cause for concern. This narrative review analyzes the strengths and weaknesses of the different alignment strategies and identifies the main areas of debate.

  View details for DOI 10.1177/21925682251331048

  View details for PubMedID 40632289

  View details for PubMedCentralID PMC12254617

• Patient Reported Outcome Measurements in Adult Spinal Deformity: A Narrative Review GLOBAL SPINE JOURNAL Kelly, M. P., Smith, J. S., van Hooff, M. 2025; 15 (3_SUPPL): 87S-94S

  Abstract

  Study DesignNarrative review.ObjectivesTo review the current state-of-the-art in patient reported outcome measurements (PROMs) in adult spinal deformity (ASD) surgery.MethodsPubMed was queried for publications related to PROM usage in ASD. PROM properties including responsiveness to change and thresholds for clinically relevant change were reviewed.ResultsDespite many reports using PROMs in ASD, there are little data to support superiority of any particular PROM. The Scoliosis Research Society-22r is a disease-specific measure that is responsive to change across pain, function, and self-image domains. The Patient Reported Outcome Measurement Information System (PROMIS) is a domain-specific measure available in computer adaptive tests, which may reduce question burden and ease administration for both patients and providers. Minimum clinically important differences, minimum detectable changes, and patient-acceptable symptom states have been proposed.ConclusionsPROMs are an essential component of modern, value-based ASD care, irrespective of academic pursuits. The SRS-22r is a validated disease specific measure, though this may be supplanted by computer-adaptive tests such as PROMIS to reduce the question burden. There is no PROMIS question set for self-image, which must be developed to cover all pertinent ASD domains.

  View details for DOI 10.1177/21925682231188811

  View details for Web of Science ID 001525582200002

  View details for PubMedID 40632293

  View details for PubMedCentralID PMC12254653

• Current Concepts on Imaging and Artificial Intelligence of Osteosarcopenia in the Aging Spine - A Review for Spinal Surgeons by the SRS Adult Spinal Deformity Task Force on Senescence. Spine Walker, C. T., Babadjouni, R., Gibbs, W., Lord, E., Gausper, A., Osorio, J., Molina, C., Jones, K., van Hooff, M., Theologis, A., Yagi, M., Blakemore, L., Shah, S., Hu, S., de Kleuver, M., Pizones, J., Kelly, M., Pellise, F., Ames, C., Eastlack, R. 2025

  Abstract

  Narrative review.To explore the intersection of osteoporosis, sarcopenia, radiomics, and machine learning in spine surgery, with a focus on clinical applications and opportunities for advancing assessment and predictive modeling methods.Osteoporosis and sarcopenia are significant contributors to negative outcomes in the aging adult spine. Current methodologies for evaluating these disease states remain limited, with significant variability and poor standardization. Advances in computational medicine provide a novel opportunity to improve quantitative assessment of osteosarcopenia, as demonstrated in other areas of medicine. Using radiomic approaches for predictive outcome modeling in spine surgery remains largely untapped.A comprehensive literature search was performed. Articles were identified using the search terms "osteoporosis," "sarcopenia," "osteosarcopenia," "radiomics," "spine surgery," and "machine learning." Relevant studies were selected based on their focus on the intersection of these topics, emphasizing clinical, imaging, and computational methodologies in spine surgery.This review highlights the existing conventional and research methods of assessing both osteoporosis and sarcopenia, particularly regarding their clinical application in spine surgery. Areas of research within the radiomic space for both conditions are also discussed to describe opportunities for growth of future research and areas of focus needed to advance the field of spine surgery alongside the rapid growth of artificial intelligence.Understanding the relationship between osteoporosis, sarcopenia, and frailty is essential to improving outcomes in spine surgery. Advanced imaging and machine learning approaches offer the potential for more precise assessments and tailored interventions. The Scoliosis Research Society Adult Spinal Deformity Task Force on Senescence has identified this as an area of maximal importance for strategic growth and development of the field.

  View details for DOI 10.1097/BRS.0000000000005426

  View details for PubMedID 40511548

• Musculoskeletal biomarkers in health and disease: implications for the aging spine-a review for spinal surgeons by the SRS adult spinal deformity task force on senescence. Spine deformity Azad, T. D., Li, M. W., Ping-Yeh, C., Jones, K. E., Lord, E. L., Molina, C. A., Walker, C. T., Osorio, J. A., Pizones, J., Theologis, A., van Hooff, M., Yagi, M., Kelly, M. P., de Kleuver, M., Hu, S. S., Shah, S. A., Pellisé, F., Walston, J. D., Eastlack, R. K., Ames, C. P. 2025

  Abstract

  The incidence of spine-related pathologies is expected to increase in developed countries due to ongoing fundamental demographic shifts toward an older population. These changes present significant challenges to public health, as healthcare systems worldwide must confront the burden of musculoskeletal aging and its related consequences. Here, we synthesize current knowledge on the biologic mechanisms underlying musculoskeletal aging, focusing on the implications for the aging spine. The complexity of the aging process, characterized by a convoluted interplay between genetic, environmental, and lifestyle factors, necessitates a comprehensive understanding of the biologic processes and reliable methods of surveying biologic states to inform effective diagnostic, predictive, and prognostic strategies. Biomarkers emerge as invaluable tools in this domain, offering insights into the early detection, risk assessment, and targeted intervention for age-related musculoskeletal decline. This review highlights various biomarker types including diagnostic, predictive, and prognostic, and explores their distinct roles in enhancing our understanding of musculoskeletal aging. Navigating the interconnected landscape of cellular senescence, sarcopenia, osteoporosis, and frailty, this review underscores the critical importance of developing personalized care approaches for the aging population. By identifying and integrating functional biomarkers, researchers and clinicians can elucidate the underlying mechanisms and devise tailored strategies to alleviate the musculoskeletal decline associated with the aging process. We envision an "active surveillance" future where biomarkers of musculoskeletal aging are integrated into clinical practice, empowering clinicians to make proactive, data-driven decisions that improve spine health for older adults.

  View details for DOI 10.1007/s43390-025-01124-w

  View details for PubMedID 40465097

  View details for PubMedCentralID 9244680

• Anterior release is not needed to restore kyphosis in moderate AIS with hypokyphosis. Spine deformity Louer, C. R., Pennings, J. S., Petcharaporn, M., Hariharan, A. R., Vorhies, J. S., Kelly, M. P., Shah, S. A., Newton, P. O., Yaszay, B., Group, H. S. 2025

  Abstract

  PURPOSE: The purpose of this study is to evaluate if AR offers improved 3D kyphosis restoration during PSF for hypokyphosis in moderate AIS (<70° coronal cobb), where the decision for AR is likely driven by sagittal concerns.METHODS: A multicenter pediatric spine registry was queried for hypokyphotic (<10°) Lenke 1-4 AIS patients aged<20years with>2-year surgical follow-up. Coronal curves were limited to<70°. A linear mixed model was created to predict 2-year 3D kyphosis by treatment and pre-op 3D kyphosis, while controlling for age, sex, thoracic coronal deformity and flexibility, osteotomy use, implant characteristics, surgery recency, and surgeon.RESULTS: 1384 patients were included with 53 (3.8%) undergoing PSF+AR. Mean preop 3D kyphosis was similar between PSF and PSF+AR groups (-3.7° vs. -0.5°; p=0.08). PSF-AR had similar 2-year 3D kyphosis (23.0° [95% CI 20.5-25.4°] vs. 23.3° [22.9-23.6°]) and correction (26.7° [23.3-29.9°] vs. 23.7° [23.3-24.2°]) compared to PSF. When controlling for covariates, the models demonstrated no difference between approach (p=0.058) or interaction of approach and preop 3D kyphosis (p=0.31). Post-hoc power analysis showed an adequate sample size to detect a difference of 5° between approaches. PSF+AR had longer surgical times (324 vs. 266min, p<0.001) though no significant increase in overall complications (17% vs. 12.4%) compared to PSF alone.CONCLUSION: In AIS patients with coronal curve<70° and 3D hypokyphosis of 10 to -40°, treatment with PSF+AR did not improve 2-year sagittal correction more than PSF alone. Surgeon identity and surgery recency influenced post-operative kyphosis more than any other patient or surgical factor.

  View details for DOI 10.1007/s43390-025-01119-7

  View details for PubMedID 40459687

• Effects of Sustained Tensile Distraction on Vertebrae and Intervertebral Disc Growth JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Salari, P., Easson, G. W. D., Broz, K. S., Kelly, M. P., Tang, S. Y. 2025; 107 (10): 1107-1115

  Abstract

  Directed growth modulation is commonly utilized as a surgical treatment for early-onset scoliosis. Growing rods are instrumented on the spine and apply sustained tension on the immature spine for a substantial amount of time, with the clinical goal of accommodating axial expansion of the spine. Despite the use of growing rods in humans, the mechanobiology of the spinal tissues under tensile loading remains relatively unknown. To bridge this knowledge gap, we developed a preclinical mouse model that allows for mechanistic investigations of sustained tension on the spine.Using custom 3D-printed washers and tunable springs, we distracted across the seventh and ninth caudal vertebrae of adolescent and young adult C57BL/6 female mice with forces that were approximately 2 times the body mass of the animal. The springs were replaced weekly to maintain tension for the duration of the experiment. A set of 6-week-old animals were first instrumented for 10 weeks to evaluate the feasibility and tolerability. Subsequently, the 6- and 12-week-old experimental animals were instrumented until they were 20 weeks of age in order to evaluate the effects of tension until adulthood. The spines were monitored using digital radiography and micro-computed tomography (µCT), and the intervertebral discs (IVDs) were evaluated using mechanical testing and compositional assays.The device was well tolerated and caused no notable complications. The tensile forces lengthened the vertebrae in the 6-week-old animals that were instrumented for 14 weeks and in the 12-week-old animals that were instrumented for 8 weeks. Increased IVD heights were observed in the 6-week-old animals but not in the 12-week-old animals. The porosity of the vertebral end plates increased following instrumentation in all groups but progressively recovered over time.Distraction accelerated the lengthening of the vertebrae and the heightening of the IVD, with no observable degeneration or decline in the mechanical performance of the IVDs for these distraction conditions.This model will be useful for investigating how spinal tissues adapt to directed growth modulation with maturation and aging.

  View details for DOI 10.2106/JBJS.24.00224

  View details for Web of Science ID 001492084700003

  View details for PubMedID 40179155

  View details for PubMedCentralID PMC12080362

• Impact of Surgical Upper Lumbar Changes on Unfused Lower Lumbar Segments in Adolescent Idiopathic Scoliosis. Spine Hariharan, A. R., Bryan, T., Nugraha, H. K., Feldman, D. S., Vorhies, J. S., Louer, C. R., Newton, P. O., Shah, S. A., Shufflebarger, H. L., Fletcher, N. D., Lonner, B. S., Kelly, M. P., Harms Study Group, Larson, A. N., Buckland, A., Alanay, A., Samdani, A., Jain, A., Lonner, B., Roye, B., Yaszay, B., Yilgor, C., Hoernschmeyer, D., Hedequist, D., Sucato, D., Clements, D., Miyanji, F., Shufflebarger, H., Flynn, J., Mac Thiong, J. M., Murphy, J., Pahys, J., Bachmann, K., Neal, K., Blakemore, L., Haber, L., Lenke, L., Abel, M., Erickson, M., Glotzbecker, M., Kelly, M., Vitale, M., Marks, M., Gupta, M., Fletcher, N., Cahill, P., Sponseller, P., Gabos, P., Newton, P., Sturm, P., Betz, R., Cho, R. H., Parent, S., George, S., Hwang, S., Shah, S., Garg, S., Errico, T., Upasani, V. 2024

  Abstract

  STUDY DESIGN: Retrospective review.OBJECTIVE: To determine the impact of upper lumbar lordosis changes in the fused segment on compensatory kyphotic or lordotic changes in the unfused lower lumbar spine in patients with Adolescent Idiopathic Scoliosis (AIS).SUMMARY OF BACKGROUND DATA: While the distribution of lordosis and interplay between fused/unfused segments has been studied in adults, less is known about this in AIS. We hypothesize that increased FSLL can result in compensatory kyphosis of the unfused distal segments.METHODS: A retrospective review of Lenke 1/2 patients who underwent posterior spinal fusion (PSF) to L1, L2, or L3 with a minimum follow-up of two years. Coronal Cobb angles, thoracic kyphosis, lumbar lordosis, and spino-pelvic parameters (T4PA, L1PA, PT, SS, PI, PI-LL, SVA) were measured. Custom MATLAB scripts were used for 3D segmental lordosis calculations. Statistical analysis including linear regression analyses and interaction models assessed the relationship between fused segment lumbar lordosis (FSLL), LIV, and thoracic kyphosis (TK) on lower lumbar compensatory alignment.RESULTS: 158 patients met inclusion criteria. Changes in FSLL affected segmental lordosis of unfused segments, including loss of distal lordosis. In the L1 LIV group, increased FSLL increased L1-L2 lordosis (B=0.35 (P=0.003)). In LIV L2, increased FSLL increased L3-4 lordosis (B=0.2 (P=0.001)) and decreased L4-L5 lordosis (B=-0.23 (P=0.012). For LIV L3, increased FSLL caused reduction in lordosis of L4-5 (B=-0.14 (P=0.026)) and L5-S1 (B=-0.14 (P=0.034)). Changes in TK also had varying impacts on the unfused segments. The interaction model with LIV levels reveals that the compensation strategy can vary depending on specific fusion levels, although not significant. Overall sagittal alignment was maintained and PI-LL remained <10°. Pre- and postoperative T4-L1PA had minimal difference to each other indicating maintained sagittal harmony.CONCLUSIONS: In this observational study of segmental changes in lumbar lordosis in AIS, post-operative changes in the fused segments can result in iatrogenic changed in the unfused lower segments to maintain spinal balance. Understanding normal segmental lumbar lordosis distribution is critical in surgical planning (i.e. rod contouring) and in understanding the health of the unfused segments long term.

  View details for DOI 10.1097/BRS.0000000000005240

  View details for PubMedID 39668798

• The T4-L1-Hip Axis: Sagittal Spinal Realignment Targets in Long-Construct Adult Spinal Deformity Surgery JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Hills, J., Mundis, G. M., Klineberg, E. O., Smith, J. S., Line, B., Gum, J. L., Protopsaltis, T. S., Hamilton, D., Soroceanu, A., Eastlack, R., Nunley, P., Kebaish, K. M., Lenke, L. G., Hostin Jr, R. A., Gupta, M. C., Kim, H., Ames, C. P., Burton, D. C., Shaffrey, C. I., Schwab, F. J., Lafage, V., Lafage, R., Bess, S., Kelly, M. P., Int Spine Study Grp 2024; 106 (23)

  View details for DOI 10.2106/JBJS.23.00372

  View details for Web of Science ID 001369904800010

• Using Multimodal Assessments to Reevaluate Depression Designations for Spine Surgery Candidates JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Benedict, B., Frumkin, M., Botterbush, K., Javeed, S., Zhang, J. K., Yakdan, S., Neuman, B. J., Steinmetz, M. P., Ghogawala, Z., Kelly, M. P., Goodin, B. R., Piccirillo, J. F., Ray, W. Z., Rodebaugh, T. L., Greenberg, J. K. 2024; 106 (18): 1704-1712

  Abstract

  Depression is common in spine surgery candidates and may influence postoperative outcomes. Ecological momentary assessments (EMAs) can overcome limitations of existing depression screening methods (e.g., recall bias, inaccuracy of historical diagnoses) by longitudinally monitoring depression symptoms in daily life. In this study, we compared EMA-based depression assessment with retrospective self-report (a 9-item Patient Health Questionnaire [PHQ-9]) and chart-based depression diagnosis in lumbar spine surgery candidates. We further examined the associations of each depression assessment method with surgical outcomes.Adult patients undergoing lumbar spine surgery (n = 122) completed EMAs quantifying depressive symptoms up to 5 times daily for 3 weeks preoperatively. Correlations (rank-biserial or Spearman) among EMA means, a chart-based depression history, and 1-time preoperative depression surveys (PHQ-9 and Psychache Scale) were analyzed. Confirmatory factor analysis was used to categorize PHQ-9 questions as somatic or non-somatic; subscores were compared with a propensity score-matched general population cohort. The associations of each screening modality with 6-month surgical outcomes (pain, disability, physical function, pain interference) were analyzed with multivariable regression.The association between EMA Depression scores and a depression history was weak (r rb = 0.34 [95% confidence interval (CI), 0.14 to 0.52]). Moderate correlations with EMA-measured depression symptoms were observed for the PHQ-9 (r s = 0.51 [95% CI, 0.37 to 0.63]) and the Psychache Scale (r s = 0.68 [95% CI, 0.57 to 0.76]). Compared with the matched general population cohort, spine surgery candidates endorsed similar non-somatic symptoms but significantly greater somatic symptoms on the PHQ-9. EMA Depression scores had a stronger association with 6-month surgical outcomes than the other depression screening modalities did.A history of depression in the medical record is not a reliable indication of preoperative depression symptom severity. Cross-sectional depression assessments such as PHQ-9 have stronger associations with daily depression symptoms but may conflate somatic depression symptoms with spine-related disability. As an alternative to these methods, mobile health technology and EMAs provide an opportunity to collect real-time, longitudinal data on depression symptom severity, potentially improving prognostic accuracy.Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.23.01195

  View details for Web of Science ID 001315253900013

  View details for PubMedID 39052762

  View details for PubMedCentralID PMC12010100

• Self-image in spinal deformity: a state-of-the-art review SPINE DEFORMITY Stone, L. E., Sindewald, R., Kelly, M. P. 2024; 12 (5): 1179-1202

  Abstract

  To review the current literature surrounding the assessment of self-image in pediatric and adult spinal deformity.The literature were reviewed for studies examining patient-reported outcome measurements (PROM) and self-image in pediatric and adult spinal deformity. PROM performance metrics were collected and described. The relationships between self-image PROM and patient outcomes, including satisfaction, were described.Several self-image PROM exist, including the Scoliosis Research Society-22r (SRS-22r) self-image domain, the Body Image Disturbance Questionnaire (BIDQ), and the Spinal Appearance Questionnaire (SAQ). The most commonly used is the self-image domain of the SRS-22r. It is validated in adult and pediatric spinal deformity and is correlated with patient desire for surgery and satisfaction after surgery. This domain is limited by floor and ceiling effects.Self-image assessment is critical to both pediatric and adult spinal deformity surgeries. The SRS-22r self-image domain is the most frequently reported PROM for this health domain. While valid in both surgical cohorts, this PROM is affected by floor and ceiling effects which limits the ability to discriminate between health states. Given the overall importance of this domain to patients with spinal deformity further efforts are needed to improve discrimination without gross increases in PROM question burden, which may limit broad acceptance and use.

  View details for DOI 10.1007/s43390-024-00875-2

  View details for Web of Science ID 001216943100003

  View details for PubMedID 38696080

  View details for PubMedCentralID 61299

• <i>CORR</i> Insights®: Can a Psychological Profile Predict Successful Return to Full Duty After a Musculoskeletal Injury? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Kelly, M. 2024; 482 (4): 630-632

  View details for DOI 10.1097/CORR.0000000000003008

  View details for Web of Science ID 001235699400005

  View details for PubMedID 38363558

  View details for PubMedCentralID PMC10936998

• The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Larson, A., Polly, D. W., Sponseller, P. D., Kelly, M. P., Richards, B., Garg, S., Parent, S., Shah, S. A., Weinstein, S. L., Crawford, C. H., Sanders, J. O., Blakemore, L. C., Oetgen, M. E., Fletcher, N. D., Kremers, W. K., Marks, M. C., Brearley, A. M., Aubin, C., Sucato, D. J., Labelle, H., Erickson, M. A. 2024; 106 (3): 180-189

  View details for DOI 10.2106/JBJS.23.00178

  View details for Web of Science ID 001158711200003

• Disparities in indications and outcomes reporting for pediatric tethered cord surgery: The need for a standardized outcome assessment tool CHILDS NERVOUS SYSTEM Findlay, M. C., Tenhoeve, S., Terry, S. A., Iyer, R. R., Brockmeyer, D. L., Kelly, M. P., Kestle, J. R. W., Gonda, D., Ravindra, V. M. 2023: 1111-1120

  Abstract

  Tethered cord syndrome (TCS) is characterized by abnormal attachment of the spinal cord neural elements to surrounding tissues. The most common symptoms include pain, motor or sensory dysfunction, and urologic deficits. Although TCS is common in children, there is a significant heterogeneity in outcomes reporting. We systematically reviewed surgical indications and postoperative outcomes to assess the need for a grading/classification system.PubMed and EMBASE searches identified pediatric TCS literature published between 1950 and 2023. Studies reporting surgical interventions, ≥ 6-month follow-up, and ≥ 5 patients were included.Fifty-five studies representing 3798 patients were included. The most commonly reported non-urologic symptoms were nonspecific lower-extremity motor disturbances (36.4% of studies), lower-extremity/back pain (32.7%), nonspecific lower-extremity sensory disturbances (29.1%), gait abnormalities (29.1%), and nonspecific bowel dysfunction/fecal incontinence (25.5%). Urologic symptoms were most commonly reported as nonspecific complaints (40.0%). After detethering surgery, retethering was the most widely reported non-urologic outcome (40.0%), followed by other nonspecific findings: motor deficits (32.7%), lower-extremity/back/perianal pain (18.2%), gait/ambulation function (18.2%), sensory deficits (12.7%), and bowel deficits/fecal incontinence (12.7%). Commonly reported urologic outcomes included nonspecific bladder/urinary deficits (27.3%), bladder capacity (20.0%), bladder compliance (18.2%), urinary incontinence/enuresis/neurogenic bladder (18.2%), and nonspecific urodynamics/urodynamics score change (16.4%).TCS surgical literature is highly variable regarding surgical indications and reporting of postsurgical outcomes. The lack of common data elements and consistent quantitative measures inhibits higher-level analysis. The development and validation of a standardized outcomes measurement tool-ideally encompassing both patient-reported outcome and objective measures-would significantly benefit future TCS research and surgical management.

  View details for DOI 10.1007/s00381-023-06246-y

  View details for Web of Science ID 001120242500001

  View details for PubMedID 38072858

  View details for PubMedCentralID PMC10972940

• Defining Clinically Relevant Proximal Junctional Kyphosis. International journal of spine surgery Hills, J., Kelly, M. P. 2023; 17 (S2): S4-S8

  Abstract

  Proximal junctional kyphosis and failure are not infrequent complications of adult spinal deformity reconstructions. Efforts to define proximal junctional kyphosis have ranged from expert opinions to statistical analyses of large databases. These approaches fail to recognize that proximal junctional kyphosis/failure/breakdown is likely a spectrum of manifestations secondary to spinal fusions and spinal alignment. The dichotomization (clinically irrelevant vs clinically relevant) of continuous measures will lead to misclassification and misdiagnosis. As adult spinal deformity moves to a precision-medicine-based approach (also known as personalized medicine), work is required to develop probabilistic models to inform patients and surgeons about the likely survivorship of a proximal junctional failure. As such, it is likely better to call proximal junctional segment kyphosis without symptoms "asymptomatic proximal junctional kyphosis" rather than to determine thresholds for "symptomatic" or "clinically relevant."

  View details for DOI 10.14444/8516

  View details for PubMedID 37704378

  View details for PubMedCentralID PMC10626146

• Machine Learning for Benchmarking Adolescent Idiopathic Scoliosis Surgery Outcomes SPINE Gupta, A. Y., Oh, I., Kim, S. C., Marks, M., Payne, P. P., Ames, C., Pellise, F. M., Pahys, J. D., Fletcher, N. O., Newton, P. P., Kelly, M., Harms Study Group 2023; 48 (16): 1138-1147

  Abstract

  Retrospective cohort.The aim of this study was to design a risk-stratified benchmarking tool for adolescent idiopathic scoliosis (AIS) surgeries.Machine learning (ML) is an emerging method for prediction modeling in orthopedic surgery. Benchmarking is an established method of process improvement and is an area of opportunity for ML methods. Current surgical benchmark tools often use ranks and no "gold standards" for comparisons exist.Data from 6076 AIS surgeries were collected from a multicenter registry and divided into three datasets: encompassing surgeries performed (1) during the entire registry, (2) the past 10 years, and (3) during the last 5 years of the registry. We trained three ML regression models (baseline linear regression, gradient boosting, and eXtreme gradient boosted) on each data subset to predict each of the five outcome variables, length of stay (LOS), estimated blood loss (EBL), operative time, Scoliosis Research Society (SRS)-Pain and SRS-Self-Image. Performance was categorized as "below expected" if performing worse than one standard deviation of the mean, "as expected" if within 1 SD, and "better than expected" if better than 1 SD of the mean.Ensemble ML methods classified performance better than traditional regression techniques for LOS, EBL, and operative time. The best performing models for predicting LOS and EBL were trained on data collected in the last 5 years, while operative time used the entire 10-year dataset. No models were able to predict SRS-Pain or SRS-Self-Image in any useful manner. Point-precise estimates for continuous variables were subject to high average errors.Classification of benchmark outcomes is improved with ensemble ML techniques and may provide much needed case-adjustment for a surgeon performance program. Precise estimates of health-related quality of life scores and continuous variables were not possible, suggesting that performance classification is a better method of performance evaluation.

  View details for DOI 10.1097/BRS.0000000000004734

  View details for Web of Science ID 001039202100006

  View details for PubMedID 37249385

• The Thoracolumbar Inflection Point in a Population of Asymptomatic Volunteers: A Multi-Ethnic Alignment Normative Study Cohort Study GLOBAL SPINE JOURNAL Malka, M., Sardar, Z. M., Czerwonka, N., Coury, J. R., Reyes, J. L., Le Huec, J., Bourret, S., Hasegawa, K., Wong, H., Liu, G., Hey, H., Riahi, H., Kelly, M., Lenke, L. G. 2025; 15 (2): 438-444

  Abstract

  Prospective cohort study.To show population variance in the Inflection Point (IP) and its role in defining maximum Thoracic Kyphosis (TK) and Lumbar Lordosis (LL).468 asymptomatic adult volunteers were included in the Multi-Ethnic Normative Alignment Study (MEANS). To find parameters correlating with IP, the vertebrae and discs were numbered such that C7 was 0, T1 was 1, with T1-T2 disc being 1.5, etc. Statistical analysis was performed by a correlation matrix for IP and the 9 other selected parameters along with linear regressions.The overall mean IP was 12.44 approximately corresponding to T12-L1 disc with the median being 12.50, range was T8-L4. The cohort was then stratified by sex and ethnicity, but there was no significant difference in IP between groups. IP in younger subjects was 13 (L1), compared to 12.5 (T12-L1 disc) in older subjects (P < .05). IP was moderately correlated with the TK apex (r = .66). No strong correlation was found between IP and LL magnitude or apex, TK magnitude, sacral slope, or Pelvic Incidence (PI). In terms of other sagittal parameters, PI and LL demonstrated a significant positive correlation. PI and TK did not have a strong association.The mean IP was at the T12-L1 disc, however IP ranged from T8 to L4. Older subjects tended to have a relatively more cephalad IP. No radiographic variable was found to be a strong predictor of the IP. TK apex was found to have a moderate correlation.

  View details for DOI 10.1177/21925682231193619

  View details for Web of Science ID 001039895200001

  View details for PubMedID 37534454

  View details for PubMedCentralID PMC11877584

• Letter to the editor regarding "Robotic and navigated pedicle screws are safer and more accurate than fluoro- scopic freehand screws: a systematic review and meta- analysis" by Matur et al. SPINE JOURNAL Greenberg, J. K., Pelle, D., Clifton, W., Javeed, S., Ray, W. Z., Kelly, M. P., Wang, J. C., Harrop, J. S., Vaccaro, A. R., Ghogawala, Z., Savage, J. W., Steinmetz, M. P. 2023; 23 (5): 1234-1235

  View details for DOI 10.1016/j.spinee.2023.04.008

  View details for Web of Science ID 001042003800001

  View details for PubMedID 37084821

• SRS-22r Self-Image After Surgery for Adolescent Idiopathic Scoliosis at 10-year Follow-up SPINE Stone, L. E. V., Upasani, V. V. M., Pahys, J. M. D., Fletcher, N. D. G., George, S. G. A., Shah, S. A. P., Bastrom, T. P. E., Bartley, C. E. G., Lenke, L. G. O., Newton, P. O. P., Kelly, M. P., Harms Study Grp 2023; 48 (10): 683-687

  Abstract

  Retrospective cohort.To examine SRS-Self Image scores at up to 10 years after surgery for adolescent idiopathic scoliosis (AIS).Self-image is complex with implications for surgical and patient-reported outcomes after AIS surgery. Surgically modifiable factors that impact self-image are inconsistently reported in the literature with few longer-term reports. We examined the rate and durability of self-image improvement.An AIS registry was queried for patients with up to 10 years of follow-up after AIS surgery. A mixed effects model estimated change in SRS-22 Self Image from baseline to 6 weeks, 1 year, 2 years, 5 years, and 10 years. All enrolled patients contributed data to the mixed effects models. A sub-analysis of patients with 1-year and 10-year follow-up evaluated worsening/static/improved SRS-22 Self Image scores examined stability of scores over that timeline. Baseline demographic data and 1-year deformity magnitude data were compared between groups using parametric and nonparametric tests as appropriate.Data from 4608 patients contributed data to the longitudinal model; 162 had 1-year and 10-year data. Mean SRS-Self Image improvement at 10-year follow-up was 1.0 (95% CI: 0.9-1.1) point. No significant changes in Self-Image domain scores were estimated from 1-year to 10-year (all P >0.05) postoperative. Forty (25%) patients had SRS-Self Image worsening from 1 year to 10 years, 36 (22%) improved, and 86 (53%) were unchanged. Patients who worsened over 10 years had lower SRS-Self Image at baseline than those unchanged at enrollment (3.3 vs. 3.7, P =0.007). Neither radiographic parameters nor SRS-Mental Health were different at baseline for the enrolled patients.Ten years after surgery, 75% of patients reported similar or better SRS-Self Image scores than one year after surgery. Nearly 25% of patients reported worsening self-image at 10 years. Patients who worsened had lower baseline SRS-Self Image scores, without radiographic or mental health differences at baseline or follow-up.

  View details for DOI 10.1097/BRS.0000000000004620

  View details for Web of Science ID 000999616700004

  View details for PubMedID 36917707

• Randomized, controlled trial of two tranexamic acid dosing protocols in adult spinal deformity surgery SPINE DEFORMITY Clohisy, J. C. F., Lenke, L. G., El Dafrawy, M. H., Wolfe, R. C., Frazier, E., Kelly, M. P. 2022; 10 (6): 1399-1406

  Abstract

  Tranexamic acid (TXA) is an anti-fibrinolytic effective in reducing blood loss in orthopedic surgery. The appropriate dosing protocol for adult spinal deformity (ASD) surgery is not known. The purpose of this study was to evaluate two TXA protocols [low dose (L): 10 mg/kg bolus, 1 mg/kg/hr infusion; high dose (H): 50 mg/kg, 5 mg/kg/hr] in complex ASD surgery.Inclusion criteria were ASD reconstructions with minimum 10 fusion levels or planned 3-column osteotomy (3CO). Standard demographic and surgical data were collected. Intraoperative estimated blood loss (EBL) was calculated by suction canisters minus irrigation plus estimated blood lost in sponges, estimated to the nearest 50 mL. Serious adverse events (SAE) were defined a priori as: venothromboembolic event (VTE), cardiac arrhythmia, myocardial infarction, renal dysfunction, and seizure. All SAE were recorded. Simple t tests compared EBL between groups. Mean EBL by total blood volume (TBV), transfusion volume, complications related to TXA were secondary outcomes.Sixty-two patients were enrolled and 52 patients completed the study; 25 were randomized to H and 27 to L. Demographic and surgical variables were not different between the two groups. EBL was not different between groups (H: 1596 ± 933 cc, L: 2046 ± 1105 cc, p = 0.12, 95% CI: - 1022 to 122 cc). EBL as a percentage of TBV was lower for the high-dose group (H: 29.5 ± 14.8%, L: 42.5 ± 26.2%, p = 0.03). Intraoperative transfusion volume (H: 961 ± 505 cc, L: 1105 ± 808 cc, p = 0.5) and post-operative transfusion volume (H: 513 ± 305 cc, L: 524 ± 245 cc, p = 0.9) were not different. SAE related to TXA were not different (p = 0.7) and occurred in 2 (8%) H and 3 (11%) L. There was one seizure (H), 2 VTE, and 2 arrhythmias.No differences in EBL, transfusion volume, nor SAE were observed between H and L dose TXA protocols. High dose was associated with decreased TBV loss (13%). Further prospective study, with pharmacologic analysis, is required to determine appropriate TXA dosage in ASD surgeries.Therapeutic Level II.The study was registered at Clinicaltrials.gov (NCT02053363) February 3, 2014.

  View details for DOI 10.1007/s43390-022-00539-z

  View details for Web of Science ID 000815568700001

  View details for PubMedID 35751772

  View details for PubMedCentralID 2772136

• Cellular immunophenotype of major spine surgery in adults SPINE DEFORMITY Turnbull, I. R., Hess, A., Fuchs, A., Frazier, E. P., Ghosh, S., Hughes, S., Kelly, M. P. 2022; 10 (6): 1375-1384

  Abstract

  ASD reconstructions are a major, sterile traumatic insult, likely causing perturbations to the immune systems. The immune response to surgery is associated with outcomes. The purpose of this study was to examine for a detectable immune signature associated with ASD surgery.Consecutive patients undergoing ASD surgery were approached and enrolled. Peripheral blood was drawn before incision, 4 h after, and 24 h after incision. Blood was stabilized and comprehensive flow cytometric immunophenotyping performed. Leukocyte population frequency, absolute number and activation marker expression were defined. Immunologic features were defined and analyzed by hierarchical clustering and principal component analysis (PCA). Changes over time were evaluated by repeated measures ANOVA (RMANOVA) and were corrected for a 1% false discovery rate. Post hoc testing was by Dunn's test. p values of <  = 0.05 were considered significant.Thirteen patients were enrolled; 11(85%) F, 65.4 years (± 7.5), surgical duration 418 ± 83 min, EBL 1928 ± 1253 mL. Hierarchical clustering and PCA found consistent time from incision-dependent changes. HLA-DR and activating co-stimulatory molecule CD86 were depressed at 4 h and furthermore at 24 h on monocyte surfaces. CD4 + HLA-DR + T cells, but not CD8 +, increased over time with increased expression of PD-1 at 4 and 24 h.Despite surgery and patient heterogeneity, we identified an immune signature associated with the sterile trauma of ASD surgery. Circulating leukocyte populations change in composition and signaling protein expression after incision and persisting to 24 h after incision, suggesting an immunocompromised state. Further work may determine relationships between this state and poor outcomes after surgery.

  View details for DOI 10.1007/s43390-022-00524-6

  View details for Web of Science ID 000810836500001

  View details for PubMedID 35699911

  View details for PubMedCentralID 3427603

• Leveraging Artificial Intelligence and Synthetic Data Derivatives for Spine Surgery Research GLOBAL SPINE JOURNAL Greenberg, J. K., Landman, J. M., Kelly, M. P., Pennicooke, B. H., Molina, C. A., Foraker, R. E., Ray, W. Z. 2023; 13 (8): 2409-2421

  Abstract

  Retrospective cohort study.Leveraging electronic health records (EHRs) for spine surgery research is impeded by concerns regarding patient privacy and data ownership. Synthetic data derivatives may help overcome these limitations. This study's objective was to validate the use of synthetic data for spine surgery research.Data came from the EHR from 15 hospitals. Patients that underwent anterior cervical or posterior lumbar fusion (2010-2020) were included. Real data were obtained from the EHR. Synthetic data was generated to simulate the properties of the real data, without maintaining a one-to-one correspondence with real patients. Within each cohort, ability to predict 30-day readmissions and 30-day complications was evaluated using logistic regression and extreme gradient boosting machines (XGBoost).We identified 9,072 real and 9,088 synthetic cervical fusion patients. Descriptive characteristics were nearly identical between the 2 datasets. When predicting readmission, models built using real and synthetic data both had c-statistics of .69-.71 using logistic regression and XGBoost. Among 12,111 real and 12,126 synthetic lumbar fusion patients, descriptive characteristics were nearly the same for most variables. Using logistic regression and XGBoost to predict readmission, discrimination was similar with models built using real and synthetic data (c-statistics .66-.69). When predicting complications, models derived using real and synthetic data showed similar discrimination in both cohorts. Despite some differences, the most influential predictors were similar in the real and synthetic datasets.Synthetic data replicate most descriptive and predictive properties of real data, and therefore may expand EHR research in spine surgery.

  View details for DOI 10.1177/21925682221085535

  View details for Web of Science ID 000781840500001

  View details for PubMedID 35373623

  View details for PubMedCentralID PMC10538345

• SRS-22r question 11 is a valid opioid screen and stratifies opioid consumption SPINE DEFORMITY Inclan, P., CreveCoeur, T. S., Bess, S., Gum, J. L., Line, B. G., Lenke, L. G., Kelly, M. P. 2022; 10 (4): 913-917

  Abstract

  To validate the Scoliosis Research Society-22r (SRS-22r) question 11 (Q11) response as a measure to assess and quantify opioid consumption.A post hoc analysis of a prospective study regarding opioid use during ASD surgery was performed. Data were collected at enrollment and 2-year follow-up including the SRS-22r and a standardized data collection form (CRF) for self-reported opioid consumption. Responses to Q11 of the SS-22r were compared with responses to the opioid consumption CRF (as measured by morphine equivalent dose (MED)). Inter-rater agreement was calculated. Sensitivity and specificity for the Q11 (+) responses were calculated using MED reports as the "true" value.Cohen's kappa indicated almost perfect agreement between the MED CRF and Q11 (k = 0.878, p < 0.001). Mean daily MED consumption for patients reporting "Daily Narcotic" use was 62.0 (Median: 38.7, SD 87.5) mg; for patients reporting "Narcotics weekly or less", mean daily MED consumption was 21.6 (15.0, 29.0) mg. The positive Q11 responses were 96% sensitive and 92% specific for opioid users.SRS-22r Q11 exhibits almost perfect agreement with an independent questionnaire designed to assess opioid consumption in this cohort. "Daily narcotic" users report nearly three times the mean daily MED of "Weekly or less" users (62.0 ± 87.5 mg vs 21.6 ± 29 mg, p = 0.037). Q11 exhibited excellent sensitivity and specificity for determining opioid users and non-users. Given the need for opioid research in ASD, Q11 may be useful to use existing registries and observational cohorts to design more definitive studies regarding opioid consumption.III.

  View details for DOI 10.1007/s43390-022-00473-0

  View details for Web of Science ID 000747632400001

  View details for PubMedID 35088385

  View details for PubMedCentralID 7050825

• Dysregulation of the leukocyte signaling landscape during acute COVID-19 PLOS ONE Turnbull, I. R., Fuchs, A., Remy, K. E., Kelly, M. P., Frazier, E. P., Ghosh, S., Chang, S., Mazer, M. B., Hess, A., Leonard, J. M., Hoofnagle, M. H., Colonna, M., Hotchkiss, R. S. 2022; 17 (4): e0264979

  Abstract

  The global COVID-19 pandemic has claimed the lives of more than 750,000 US citizens. Dysregulation of the immune system underlies the pathogenesis of COVID-19, with inflammation mediated tissue injury to the lung in the setting of suppressed systemic immune function. To define the molecular mechanisms of immune dysfunction in COVID-19 we utilized a systems immunology approach centered on the circulating leukocyte phosphoproteome measured by mass cytometry. We find that although COVID-19 is associated with wholesale activation of a broad set of signaling pathways across myeloid and lymphoid cell populations, STAT3 phosphorylation predominated in both monocytes and T cells. STAT3 phosphorylation was tightly correlated with circulating IL-6 levels and high levels of phospho-STAT3 was associated with decreased markers of myeloid cell maturation/activation and decreased ex-vivo T cell IFN-γ production, demonstrating that during COVID-19 dysregulated cellular activation is associated with suppression of immune effector cell function. Collectively, these data reconcile the systemic inflammatory response and functional immunosuppression induced by COVID-19 and suggest STAT3 signaling may be the central pathophysiologic mechanism driving immune dysfunction in COVID-19.

  View details for DOI 10.1371/journal.pone.0264979

  View details for Web of Science ID 000795453600019

  View details for PubMedID 35421120

  View details for PubMedCentralID PMC9009616

• Integrin and syndecan binding peptide-conjugated alginate hydrogel for modulation of nucleus pulposus cell phenotype BIOMATERIALS Tan, X., Jain, E., Barcellona, M. N., Morris, E., Neal, S., Gupta, M. C., Buchowski, J. M., Kelly, M., Setton, L. A., Huebsch, N. 2021; 277: 121113

  Abstract

  Biomaterial based strategies have been widely explored to preserve and restore the juvenile phenotype of cells of the nucleus pulposus (NP) in degenerated intervertebral discs (IVD). With aging and maturation, NP cells lose their ability to produce necessary extracellular matrix and proteoglycans, accelerating disc degeneration. Previous studies have shown that integrin or syndecan binding peptide motifs from laminin can induce NP cells from degenerative human discs to re-express juvenile NP-specific cell phenotype and biosynthetic activity. Here, we engineered alginate hydrogels to present integrin- and syndecan-binding peptides alone or in combination (cyclic RGD and AG73, respectively) to introduce bioactive features into the alginate gels. We demonstrated human NP cells cultured upon and within alginate hydrogels presented with cRGD and AG73 peptides exhibited higher cell viability, biosynthetic activity, and NP-specific protein expression over alginate alone. Moreover, the combination of the two peptide motifs elicited markers of the NP-specific cell phenotype, including N-Cadherin, despite differences in cell morphology and multicellular cluster formation between 2D and 3D cultures. These results represent a promising step toward understanding how distinct adhesive peptides can be combined to guide NP cell fate. In the future, these insights may be useful to rationally design hydrogels for NP cell-transplantation based therapies for IVD degeneration.

  View details for DOI 10.1016/j.biomaterials.2021.121113

  View details for Web of Science ID 000700614100001

  View details for PubMedID 34492582

  View details for PubMedCentralID PMC9107941

• Myelopathic Patients Undergoing Severe Pediatric Spinal Deformity Surgery Can Improve Neurologic Function to That of Non-Myelopathic Patients by 1-Year Postoperative GLOBAL SPINE JOURNAL Cerpa, M., Zuckerman, S. L., Lenke, L. G., Kelly, M. P., Yaszay, B., Newton, P., Sponseller, P., Erickson, M., Garg, S., Pahys, J., Samdani, A., Cahill, P., McCarthy, R., Bumpass, D., Sucato, D., Boachie-Adjei, O., Shah, S., Gupta, M. 2023; 13 (5): 1384-1393

  Abstract

  Multi-center, prospective, observational cohort.To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes.Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy).Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age (P = 0.18), gender (P = 0.09), and Risser Stage (P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative (P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain (P = 0.12), self-image (P = 0.08), and satisfaction (P = 0.83) at latest follow-up.In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative.

  View details for DOI 10.1177/21925682211034837

  View details for Web of Science ID 000687719000001

  View details for PubMedID 34409864

  View details for PubMedCentralID PMC10416607

• Translating Data Analytics Into Improved Spine Surgery Outcomes: A Roadmap for Biomedical Informatics Research in 2021 GLOBAL SPINE JOURNAL Greenberg, J. K., Otun, A., Ghogawala, Z., Yen, P., Molina, C. A., Limbrick, D. D., Foraker, R. E., Kelly, M. P., Ray, W. Z. 2022; 12 (5): 952-963

  Abstract

  Narrative review.There is growing interest in the use of biomedical informatics and data analytics tools in spine surgery. Yet despite the rapid growth in research on these topics, few analytic tools have been implemented in routine spine practice. The purpose of this review is to provide a health information technology (HIT) roadmap to help translate data assets and analytics tools into measurable advances in spine surgical care.We conducted a narrative review of PubMed and Google Scholar to identify publications discussing data assets, analytical approaches, and implementation strategies relevant to spine surgery practice.A variety of data assets are available for spine research, ranging from commonly used datasets, such as administrative billing data, to emerging resources, such as mobile health and biobanks. Both regression and machine learning techniques are valuable for analyzing these assets, and researchers should recognize the particular strengths and weaknesses of each approach. Few studies have focused on the implementation of HIT, and a variety of methods exist to help translate analytic tools into clinically useful interventions. Finally, a number of HIT-related challenges must be recognized and addressed, including stakeholder acceptance, regulatory oversight, and ethical considerations.Biomedical informatics has the potential to support the development of new HIT that can improve spine surgery quality and outcomes. By understanding the development life-cycle that includes identifying an appropriate data asset, selecting an analytic approach, and leveraging an effective implementation strategy, spine researchers can translate this potential into measurable advances in patient care.

  View details for DOI 10.1177/21925682211008424

  View details for Web of Science ID 000680971700001

  View details for PubMedID 33973491

  View details for PubMedCentralID PMC9344511

• Patient-Reported Outcomes After Complex Adult Spinal Deformity Surgery: 5-Year Results of the Scoli-Risk-1 Study GLOBAL SPINE JOURNAL Zuckerman, S. L., Cerpa, M., Lenke, L. G., Shaffrey, C., Carreon, L. Y., Cheung, K. M. C., Kelly, M. P., Fehlings, M. G., Ames, C. P., Boachie-Adjei, O., Dekutoski, M. B., Kabeaish, K. M., Lewis, S. J., Matsuyama, Y., Pellise, F., Qiu, Y., Schwab, F. J., Smith, J. S., AO Spine Knowledge Forum Deformity 2022; 12 (8): 1736-1744

  Abstract

  Prospective cohort.To prospectively evaluate PROs up to 5-years after complex ASD surgery.The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers. Inclusion criteria was Cobb angle of >80°, corrective osteotomy for congenital or revision deformity, and/or 3-column osteotomy. The following PROs were measured prospectively at intervals up to 5-years postoperative: ODI, SF36-PCS/MCS, SRS-22, NRS back/leg. Among patients with 5-year follow-up, comparisons were made from both baseline and 2-years postoperative to 5-years postoperative. PROs were analyzed using mixed models for repeated measures.Seventy-seven patients (28.3%) had 5-year follow-up data. Comparing baseline to 5-year data among these 77 patients, significant improvement was seen in all PROs: ODI (45.2 vs. 29.3, P < 0.001), SF36-PCS (31.5 vs. 38.8, P < 0.001), SF36-MCS (44.9 vs. 49.1, P = 0.009), SRS-22-total (2.78 vs. 3.61, P < 0.001), NRS-back pain (5.70 vs. 2.95, P < 0.001) and NRS leg pain (3.64 vs. 2.62, P = 0.017). In the 2 to 5-year follow-up period, no significant changes were seen in any PROs. The percentage of patients achieving MCID from baseline to 5-years were: ODI (62.0%) and the SRS-22r domains of function (70.4%), pain (63.0%), mental health (37.5%), self-image (60.3%), and total (60.3%). Surprisingly, mean values (P > 0.05) and proportion achieving MCID did not differ significantly in patients with major surgery-related complications compared to those without.After complex ASD surgery, significant improvement in PROs were seen at 5-years postoperative in ODI, SF36-PCS/MCS, SRS-22r, and NRS-back/leg pain. No significant changes in PROs occurred during the 2 to 5-year postoperative period. Those with major surgery-related complications had similar PROs and proportion of patients achieving MCID as those without these complications.

  View details for DOI 10.1177/2192568220988276

  View details for Web of Science ID 000682187900001

  View details for PubMedID 33557622

  View details for PubMedCentralID PMC9609523

• Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery CreveCoeur, T. S., Yahanda, A. T., Maher, C. O., Johnson, G. W., Ackerman, L. L., Adelson, P. D., Ahmed, R., Albert, G. W., Aldana, P. R., Alden, T. D., Anderson, R. C., Baird, L., Bauer, D. F., Bierbrauer, K. S., Brockmeyer, D. L., Chern, J. J., Couture, D. E., Daniels, D. J., Dauser, R. C., Durham, S. R., Ellenbogen, R. G., Eskandari, R., Fuchs, H. E., George, T. M., Grant, G. A., Graupman, P. C., Greene, S., Greenfield, J. P., Gross, N. L., Guillaume, D. J., Haller, G., Hankinson, T. C., Heuer, G. G., Iantosca, M., Iskandar, B. J., Jackson, E. M., Jea, A. H., Johnston, J. M., Keating, R. F., Kelly, M. P., Khan, N., Krieger, M. D., Leonard, J. R., Mangano, F. T., Mapstone, T. B., McComb, J. G., Menezes, A. H., Muhlbauer, M., Oakes, W. J., Olavarria, G., O'Neill, B. R., Park, T. S., Ragheb, J., Selden, N. R., Shah, M. N., Shannon, C., Shimony, J. S., Smith, J., Smyth, M. D., Stone, S. S., Strahle, J. M., Tamber, M. S., Torner, J. C., Tuite, G. F., Wait, S. D., Wellons, J. C., Whitehead, W. E., Limbrick, D. D. 2020

  Abstract

  BACKGROUND: Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology.OBJECTIVE: To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD.METHODS: The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia≥5mm, syrinx diameter≥3mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD+OCF or PFD+OCF/VD.RESULTS: All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD+OCF), whereas 4 had OCF and VD (PFD+OCF/VD). Of those with complete data, a history of platybasia (3/10, P=.011), Klippel-Feil (2/10, P=.015), and basilar invagination (3/12, P<.001) were increased within the OCF group, whereas only basilar invagination (1/4, P<.001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8± 15.3°, P=.008) and OCF/VD (115.0± 11.6°, P=.025) groups when compared to PFD-only group (145.3± 12.7°). pB-C2 did not differ among groups.CONCLUSION: Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.

  View details for DOI 10.1093/neuros/nyaa460

  View details for PubMedID 33313928

• Neurological Complications and Recovery Rates of Patients With Adult Cervical Deformity Surgeries GLOBAL SPINE JOURNAL Kim, H., Yao, Y., Shaffrey, C., Smith, J. S., Kelly, M. P., Gupta, M., Albert, T. J., Protopsaltis, T. S., Mundis, G. M., Passias, P., Klineberg, E., Bess, S., Lafage, V., Ames, C. P., Int Spine Study Grp ISSG 2022; 12 (6): 1091-1097

  Abstract

  Retrospective cohort study.This study aims to report the incidence, risk factors, and recovery rate of neurological complications (NC) in patients with adult cervical deformity (ACD) who underwent corrective surgery.ACD patients undergoing surgery from 2013 to 2015 were enrolled in a prospective, multicenter database. Patients were separated into 2 groups according to the presence of neurological complications (NC vs no-NC groups). The types, timing, recovery patterns, and interventions for NC were recorded. Patients' demographics, surgical details, radiographic parameters, and health-related quality of life (HRQOL) scores were compared.106 patients were prospectively included. Average age was 60.8 years with a mean of 18.2 months follow-up. The overall incidence of NC was 18.9%; of these, 68.1% were major complications. Nerve root motor deficit was the most common complication, followed by radiculopathy, sensory deficit, and spinal cord injury. The proportion of complications occurring within 30 days of surgery was 54.5%. The recovery rate from neurological complication was high (90.9%), with most of the recoveries occurring within 6 months and continuing even after 12 months. Only 2 patients (1.9%) had continuous neurological complication. No demographic or preoperative radiographic risk factors could be identified, and anterior corpectomy and posterior foraminotomy were found to be performed less in the NC group. The final HRQOL outcome was not significantly different between the 2 groups.Our data is valuable to surgeons and patients to better understand the neurological complications before performing or undergoing complex cervical deformity surgery.

  View details for DOI 10.1177/2192568220975735

  View details for Web of Science ID 000681021200001

  View details for PubMedID 33222533

  View details for PubMedCentralID PMC9210226

• Selecting the "Touched Vertebra" as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Beauchamp, E. C., Lenke, L. G., Cerpa, M., Newton, P. O., Kelly, M. P., Blanke, K. M., Harms Study Grp Investigators 2020; 102 (22): 1966-1973

  Abstract

  The selection of the lowest instrumented vertebra (LIV) in patients with adolescent idiopathic scoliosis (AIS) is still controversial. Although multiple radiographic methods have been proposed, there is no universally accepted guideline for appropriate selection of the LIV. We developed a simple and reproducible method for selection of the LIV in patients with Lenke type-1 (main thoracic) and 2 (double thoracic) curves and investigated its effectiveness in producing optimal positioning of the LIV at 5 years of follow-up.The radiographs for 299 patients with Lenke type-1 or 2 AIS curves that were included in a multicenter database were evaluated after a minimum duration of follow-up of 5 years. The "touched vertebra" (TV) was selected on preoperative radiographs by 2 independent examiners. The LIV on postoperative radiographs was compared with the preoperative TV. The final LIV position in relation to the center sacral vertical line (CSVL) was assessed. The CSVL-LIV distance and coronal balance in patients who had fusion to the TV were compared with those in patients who had fusion cephalad and caudad to the TV. The sagittal plane was also reviewed.In 86.6% of patients, the LIV was selected at or immediately adjacent to the TV. Among patients with an "A" lumbar modifier, those who had fusion cephalad to the TV had a significantly greater CSVL-LIV distance than those who had fusion to the TV (p = 0.006) or caudad to the TV (p = 0.002). In the groups with "B" (p = 0.424) and "C" (p = 0.326) lumbar modifiers, there were no differences among the TV groups.We recommend the TV rule as a third modifier in the Lenke AIS classification system. Selecting the TV as the LIV in patients with Lenke type-1 and 2 curves provides acceptable positioning of the LIV at long-term follow-up. The position of the LIV was not different when fusion was performed caudad to the TV but came at the expense of fewer motion segments. Patients with lumbar modifier "A" who had fusion cephalad to the TV had greater translation of the LIV, putting these patients at risk for poor long-term outcomes.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.19.01485

  View details for Web of Science ID 000619172800011

  View details for PubMedID 32804885

• Global alignment and proportion (GAP) scores in an asymptomatic, nonoperative cohort: a divergence of age-adjusted and pelvic incidence-based alignment targets EUROPEAN SPINE JOURNAL Wegner, A. M., Iyer, S., Lenke, L. G., Kim, H., Kelly, M. P. 2020; 29 (9): 2362-2367

  Abstract

  To investigate GAP scores in an asymptomatic cohort of adults, including older adults with age-expected changes in spinal alignment.One hundred and twenty asymptomatic volunteers underwent full-body radiographic scans. Demographics and sagittal radiographic parameters (pelvic incidence, sacral slope, L1-S1 lordosis, L4-S1 lordosis, and global tilt) were measured and GAP scores calculated ( www.gapcalculator.com ). Mann-Whitney U test compared groups.Eighty-five individuals (65 female, average age 48 ± 16 years, BMI 27 ± 6 kg/cm2) were analyzed. The median GAP score was that of a proportioned spine (0, range 0-10). 20% were moderately disproportioned and 6% were severely disproportioned. The mean relative pelvic version, relative lumbar lordosis (RLL), lumbar distribution index (LDI), and relative spinopelvic alignment were all considered aligned, although the mean RLL and LDI scores were both greater than 1. When categorized by age (< 60 years, ≥ 60 years), the median GAP score of the younger group was 0 (normal), while the median GAP score of the older cohort was 1 (normal) and different from the younger group (p < 0.001).Most patients in this asymptomatic, nonoperative cohort were normally proportioned. However, a large percentage of asymptomatic volunteers were moderately or severely disproportioned. Older patients had higher scores, indicating some disproportion. There was also a small number of severely sagittally misaligned and poorly proportioned, yet asymptomatic, volunteers. Further refinement of individualized targets is needed to determine the effect on mechanical complications and quality of life given the divergent recommendations of age-adjusted targets and GAP targets.

  View details for DOI 10.1007/s00586-020-06474-9

  View details for Web of Science ID 000537336300002

  View details for PubMedID 32488438

• The Influence of Surgical Intervention and Sagittal Alignment on Frailty in Adult Cervical Deformity. Operative neurosurgery (Hagerstown, Md.) Segreto, F. A., Passias, P. G., Brown, A. E., Horn, S. R., Bortz, C. A., Pierce, K. E., Alas, H., Lafage, V., Lafage, R., Smith, J. S., Line, B. G., Diebo, B. G., Kelly, M. P., Mundis, G. M., Protopsaltis, T. S., Soroceanu, A., Kim, H. J., Klineberg, E. O., Burton, D. C., Hart, R. A., Schwab, F. J., Bess, S., Shaffrey, C. I., Ames, C. P. 2020; 18 (6): 583-589

  Abstract

  Frailty is a relatively new area of study for patients with cervical deformity (CD). As of yet, little is known of how operative intervention influences frailty status for patients with CD.To investigate drivers of postoperative frailty score and variables within the cervical deformity frailty index (CD-FI) algorithm that have the greatest capacity for change following surgery.Descriptive analysis of the cohort were performed, paired t-tests determined significant baseline to 1 yr improvements of factors comprising the CD-FI. Pearson bivariate correlations identified significant associations between postoperative changes in overall CD-FI score and CD-FI score components. Linear regression models determined the effect of successful surgical intervention on change in frailty score.A total of 138 patients were included with baseline frailty scores of 0.44. Following surgery, mean 1-yr frailty score was 0.27. Of the CD-FI variables, 13/40 (32.5%) were able to improve with surgery. Frailty improvement was found to significantly correlate with baseline to 1-yr change in CBV, PI-LL, PT, and SVA C7-S1. HRQL CD-FI components reading, feeling tired, feeling exhausted, and driving were the greatest drivers of change in frailty. Linear regression analysis determined successful surgical intervention and feeling exhausted to be the greatest significant predictors of postoperative change in overall frailty score.Complications, correction of sagittal alignment, and improving a patient's ability to read, drive, and chronic exhaustion can significantly influence postoperative frailty. This analysis is a step towards a greater understanding of the relationship between disability, frailty, and surgery in CD.

  View details for DOI 10.1093/ons/opz331

  View details for PubMedID 31701155

• Utilization of Predictive Modeling to Determine Episode of Care Costs and to Accurately Identify Catastrophic Cost Nonwarranty Outlier Patients in Adult Spinal Deformity Surgery: A Step Toward Bundled Payments and Risk Sharing. Spine Ames, C. P., Smith, J. S., Gum, J. L., Kelly, M., Vila-Casademunt, A., Burton, D. C., Hostin, R., Yeramaneni, S., Lafage, V., Schwab, F. J., Shaffrey, C. I., Bess, S., Pellisé, F., Serra-Burriel, M. 2020; 45 (5): E252-E265

  Abstract

  Retrospective review of prospectively-collected, multicenter adult spinal deformity (ASD) database.The aim of this study was to evaluate the rate of patients who accrue catastrophic cost (CC) with ASD surgery utilizing direct, actual costs, and determine the feasibility of predicting these outliers.Cost outliers or surgeries resulting in CC are a major concern for ASD surgery as some question the sustainability of these surgical treatments.Generalized linear regression models were used to explain the determinants of direct costs. Regression tree and random forest models were used to predict which patients would have CC (>$100,000).A total of 210 ASD patients were included (mean age of 59.3 years, 83% women). The mean index episode of care direct cost was $70,766 (SD = $24,422). By 90 days and 2 years following surgery, mean direct costs increased to $74,073 and $77,765, respectively. Within 90 days of the index surgery, 11 (5.2%) patients underwent 13 revisions procedures, and by 2 years, 26 (12.4%) patients had undergone 36 revision procedures. The CC threshold at the index surgery and 90-day and 2-year follow-up time points was exceeded by 11.9%, 14.8%, and 19.1% of patients, respectively. Top predictors of cost included number of levels fused, surgeon, surgical approach, interbody fusion (IBF), and length of hospital stay (LOS). At 90 days and 2 years, a total of 80.6% and 64.0% of variance in direct cost, respectively, was explained in the generalized linear regression models. Predictors of CC were number of fused levels, surgical approach, surgeon, IBF, and LOS.The present study demonstrates that direct cost in ASD surgery can be accurately predicted. Collectively, these findings may not only prove useful for bundled care initiatives, but also may provide insight into means to reduce and better predict cost of ASD surgery outside of bundled payment plans.3.

  View details for DOI 10.1097/BRS.0000000000003242

  View details for PubMedID 31513120

• Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection. Spine Line, B. G., Bess, S., Lafage, R., Lafage, V., Schwab, F., Ames, C., Kim, H. J., Kelly, M., Gupta, M., Burton, D., Hart, R., Klineberg, E., Kebaish, K., Hostin, R., Mundis, G., Eastlack, R., Shaffrey, C., Smith, J. S. 2020; 45 (4): 258-267

  Abstract

  Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database.Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone.PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF.Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) versus within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop.Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05).Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.3.

  View details for DOI 10.1097/BRS.0000000000003249

  View details for PubMedID 31524819

• The Lumbosacral Takeoff Angle Can Be Used to Predict the Postoperative Lumbar Cobb Angle Following Selective Thoracic Fusion in Patients with Adolescent Idiopathic Scoliosis. The Journal of bone and joint surgery. American volume Bachmann, K. R., Lu, E., Novicoff, W. M., Newton, P. O., Abel, M. F. 2020; 102 (2): 143-150

  Abstract

  Selective fusion of double curves in patients with scoliosis is considered to spare fusion levels. In 2011, we studied the lumbosacral takeoff angle, defined as the angle between the center-sacral vertical line and a line through the centra of S1, L5, and L4. The lumbosacral takeoff angle was shown to moderately correlate with the lumbar Cobb angle, and a predictive equation was developed to predict the lumbar Cobb angle after selective fusions. The purposes of the present study were to validate that equation in a separate cohort and to assess differences in outcomes following selective and nonselective fusion.Patients with Lenke 1B, 1C, 3B, or 3C curve patterns undergoing fusion (both selective and nonselective) with pedicle screw constructs and a minimum of 2 years of follow-up were included. Selective fusion was defined as a lowest level of fixation cephalad to or at the apex of the lumbar curve. To validate the previously derived equation, we used this data set and analysis of variance to check for differences between the actual and calculated postoperative lumbar Cobb angles. Pearson correlation, multiple linear regression, and t tests were used to explore relationships and differences between the selective and nonselective fusion groups.The mean calculated postoperative lumbar Cobb angle (and standard deviation) (22.35° ± 3.82°) was not significantly different from the actual postoperative lumbar Cobb angle (21.08° ± 7.75°), with an average model error of -1.268° (95% confidence interval, -2.649° to 0.112°). The preoperative lumbar Cobb angle was larger in patients with deformities that were chosen for nonselective fusion (50.2° versus 38.9°; p < 0.001). Performing selective fusion resulted in a 3.5° correction of the lumbosacral takeoff angle (p < 0.001), whereas nonselective fusion resulted in a 9.3° correction (p < 0.001).The lumbosacral takeoff angle can be used to predict the residual lumbar Cobb angle and may be used by surgeons to aid in the decision between selective and nonselective fusion. The change in the lumbosacral takeoff angle following selective fusion is small. Improvement in the lumbosacral takeoff angle and coronal balance is greater in association with nonselective fusion.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.19.00287

  View details for PubMedID 31644521

• Decision making in treatment of adult spinal deformity Bridwell , K., Buchowski , J., Gupta , M., Kelly , M., Zebala , L. : Gupta MC, Bridwell KH (eds) The Textbook of Spinal Surgery, 4th edition. Philadelphia, Wolters Kluwer. 2020 937-951
• PEDICLE SUBTRACTION OSTEOTOMY JBJS ESSENTIAL SURGICAL TECHNIQUES Gupta, M. C., Gupta, S., Kelly, M. P., Bridwell, K. H. 2020; 10 (1)

  Abstract

  Pedicle subtraction osteotomy (PSO) was originally performed in cases of ankylosing spondylitis. This procedure was invented because it was safer than trying to lengthen the anterior column via osteoclasis, which risked vascular injury and death1-4. PSO involves the removal of the posterior elements and the use of a vertebral body wedge to shorten the spine posteriorly and achieve sagittal-plane correction5,6. PSO has been used to correct sagittal-plane deformities not only in patients with ankylosing spondylitis but also in those with degenerative conditions or those who have previously undergone surgical procedures resulting in a loss of lumbar lordosis7,8.The fixation points are placed with pedicle screws above and below the planned osteotomy level. The posterior elements are decompressed at the level of the osteotomy and at 1 level proximally. In addition to the use of straight and angled curets, a high-speed burr is used to decancellate the vertebral body. Pedicle osteotomes are used to remove the pedicle. Temporary rods are placed. The posterior wall of the body is then impacted into the vertebral body, and the temporary rods are loosened. To close the osteotomy, the bed is extended or the spine is pushed manually, resulting in correction of the lordosis. The temporary rods are tightened. The main rods, independent of the short rods, are used to connect multiple segments several levels above and below the osteotomy site to provide final stabilization.The alternatives to PSO depend on the surgical history of the patients, as well as the flexibility and alignment of the spine. In a spine with mobile disc spaces, Smith-Petersen osteotomies can be performed posteriorly to shorten the posterior column over multiple segments to gain lordosis. A formal anterior or lateral approach can be performed to release the disc spaces and restore the disc height. A posterior release through the facet joints with segmental compression can achieve desired lumbar lordosis. A vertebral column resection can also be performed to achieve lordosis.PSO is ideal for patients who have undergone multiple spinal fusions and who have a very rigid, flat lumbar spine. A single posterior approach can be used to provide adequate correction of the flat lumbar spine up to 40°. Asymmetric PSO can also be performed to allow for correction in the coronal plane. Recently, PSO has been performed more frequently because of the improved osteotomy instrumentation, exposure to resection techniques, and improved positioning tables that allow correction of the osteotomy.

  View details for DOI 10.2106/JBJS.ST.19.00028

  View details for Web of Science ID 000568275400002

  View details for PubMedID 32368407

  View details for PubMedCentralID PMC7161731

• Mechanosensitive transcriptional coactivators MRTF-A and YAP/TAZ regulate nucleus pulposus cell phenotype through cell shape. FASEB journal : official publication of the Federation of American Societies for Experimental Biology Fearing, B. V., Jing, L., Barcellona, M. N., Witte, S. E., Buchowski, J. M., Zebala, L. P., Kelly, M. P., Luhmann, S., Gupta, M. C., Pathak, A., Setton, L. A. 2019; 33 (12): 14022-14035

  Abstract

  Cells of the adult nucleus pulposus (NP) are critically important in maintaining overall disc health and function. NP cells reside in a soft, gelatinous matrix that dehydrates and becomes increasingly fibrotic with age. Such changes result in physical cues of matrix stiffness that may be potent regulators of NP cell phenotype and may contribute to a transition toward a senescent and fibroblastic NP cell with a limited capacity for repair. Here, we investigate the mechanosignaling cues generated from changes in matrix stiffness in directing NP cell phenotype and identify mechanisms that can potentially preserve a biosynthetically active, juvenile NP cell phenotype. Using a laminin-functionalized polyethylene glycol hydrogel, we show that when NP cells form rounded, multicell clusters, they are able to maintain cytosolic localization of myocardin-related transcription factor (MRTF)-A, a coactivator of serum-response factor (SRF), known to promote fibroblast-like behaviors in many cells. Upon preservation of a rounded shape, human NP cells similarly showed cytosolic retention of transcriptional coactivator Yes-associated protein (YAP) and its paralogue PDZ-binding motif (TAZ) with associated decline in activation of its transcription factor TEA domain family member-binding domain (TEAD). When changes in cell shape occur, leading to a more spread, fibrotic morphology associated with stronger F-actin alignment, SRF and TEAD are up-regulated. However, targeted deletion of either cofactor was not sufficient to overcome shape-mediated changes observed in transcriptional activation of SRF or TEAD. Findings show that substrate stiffness-induced promotion of F-actin alignment occurs concomitantly with a flattened, spread morphology, decreased NP marker expression, and reduced biosynthetic activity. This work indicates cell shape is a stronger indicator of SRF and TEAD mechanosignaling pathways than coactivators MRTF-A and YAP/TAZ, respectively, and may play a role in the degeneration-associated loss of NP cellularity and phenotype.-Fearing, B. V., Jing, L., Barcellona, M. N., Witte, S. E., Buchowski, J. M., Zebala, L. P., Kelly, M. P., Luhmann, S., Gupta, M. C., Pathak, A., Setton, L. A. Mechanosensitive transcriptional coactivators MRTF-A and YAP/TAZ regulate nucleus pulposus cell phenotype through cell shape.

  View details for DOI 10.1096/fj.201802725RRR

  View details for PubMedID 31638828

  View details for PubMedCentralID PMC6894097

• Younger Patients Are Differentially Affected by Stiffness-Related Disability Following Adult Spinal Deformity Surgery. World neurosurgery Durand, W. M., Daniels, A. H., Hamilton, D. K., Passias, P. G., Kim, H. J., Protopsaltis, T., Lafage, V., Smith, J. S., Shaffrey, C., Gupta, M., Kelly, M. P., Klineberg, E., Schwab, F., Burton, D., Bess, S., Ames, C., Hart, R. 2019; 132: e297-e304

  Abstract

  The Lumbar Stiffness Disability Index (LSDI) assesses impact of lumbar stiffness on activities of daily living. We hypothesized that patients <60 years old would perceive greater lumbar stiffness-related functional limitation following fusion for adult spinal deformity.Patients completed the LSDI and Scoliosis Research Society 22 Questionnaire, Revised (SRS-22r) preoperatively and at 2 years postoperatively. The primary independent variable was patient age <60 versus ≥60. Multivariable regression analyses were used.Analysis included 267 patients. Patients <60 years old (51.3%) and ≥60 years old (48.7%) were evenly represented. In bivariable analysis, patients age <60 exhibited lower LSDI at baseline versus patients age ≥60 (25.7 vs. 35.5, β -9.8, P < 0.0001), but a directionally smaller difference at 2 years (26.4 vs. 32.3, β -5.8, P = 0.0147). LSDI was associated with lower SRS-22r total score among both age groups at baseline and 2 years (all P < 0.0001); the association was stronger among patients age <60 versus ≥60 at 2 years. LSDI was associated with SRS-22r satisfaction scores at 2 years among patients age <60 (P < 0.0001), but not patients age ≥60 (P = 0.2250). The difference in SRS-22r satisfaction per unit LSDI between patients <60 years old and ≥60 years old was significant (P = 0.0021).Among patients with adult spinal deformity managed operatively, higher LSDI was associated with inferior SRS-22r total score and satisfaction at 2 years postoperatively. The association between increased LSDI and worse patient-reported outcome measures was greater among patients age <60 versus ≥60. Preoperative counseling is needed for patients age <60 undergoing adult spinal deformity surgery regarding effects that lumbar stiffness may have on postoperative function and satisfaction.

  View details for DOI 10.1016/j.wneu.2019.08.169

  View details for PubMedID 31479783

• Cost-effectiveness of Operative versus Nonoperative Treatment of Adult Symptomatic Lumbar Scoliosis an Intent-to-treat Analysis at 5-year Follow-up. Spine Carreon, L. Y., Glassman, S. D., Lurie, J., Shaffrey, C. I., Kelly, M. P., Baldus, C. R., Bratcher, K. R., Crawford, C. H., Yanik, E. L., Bridwell, K. H. 2019; 44 (21): 1499-1506

  Abstract

  Secondary analysis using data from the NIH-sponsored study on adult symptomatic lumbar scoliosis (ASLS) that included randomized and observational arms.The aim of this study was to perform an intent-to-treat cost-effectiveness study comparing operative (Op) versus nonoperative (NonOp) care for ASLS.The appropriate treatment approach for ASLS continues to be ill-defined. NonOp care has not been shown to improve outcomes. Surgical treatment has been shown to improve outcomes, but is costly with high revision rates.Patients with at least 5-year follow-up data were included. Data collected every 3 months included use of NonOp modalities, medications, and employment status. Costs for index and revision surgeries and NonOp modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on reported employment status and income. Qualityadjusted life year (QALY) was determined using the SF6D.There were 81 of 95 cases in the Op and 81 of 95 in the NonOp group with complete 5-year follow-up data. Not all patients were eligible 5-year follow-up at the time of the analysis. All patients in the Op and 24 (30%) in the NonOp group had surgery by 5 years. At 5 years, the cumulative cost for Op was $96,000 with a QALY gain of 2.44 and for NonOp the cumulative cost was $49,546 with a QALY gain of 0.75 with an incremental cost-effectiveness ratio (ICER) of $27,480 per QALY gain.In an intent-to-treat analysis, neither treatment was dominant, as the greater gains in QALY in the surgery group come at a greater cost. The ICER for Op compared to NonOp treatment was above the threshold generally considered cost-effective in the first 3 years of the study but improved over time and was highly cost-effective at 4 and 5 years.2.

  View details for DOI 10.1097/BRS.0000000000003118

  View details for PubMedID 31205182

• Predicting extended operative time and length of inpatient stay in cervical deformity corrective surgery. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia Horn, S. R., Passias, P. G., Bortz, C. A., Pierce, K. E., Lafage, V., Lafage, R., Brown, A. E., Alas, H., Smith, J. S., Line, B., Deviren, V., Mundis, G. M., Kelly, M. P., Kim, H. J., Protopsaltis, T., Daniels, A. H., Klineberg, E. O., Burton, D. C., Hart, R. A., Schwab, F. J., Bess, S., Shaffrey, C. I., Ames, C. P. 2019; 69: 206-213

  Abstract

  It's increasingly common for surgeons to operate on more challenging cases and higher risk patients, resulting in longer op-time and inpatient LOS. Factors predicting extended op-time and LOS for cervical deformity (CD) patients are understudied. This study identified predictors of extended op-time and length of stay (LOS) after CD-corrective surgery. CD patients with baseline (BL) radiographic data were included. Patients were stratified by extended LOS (ELOS; >75th percentile) and normal LOS (N-LOS; <75th percentile). Op-time analysis excluded staged cases, cases >12 h. A Conditional Variable Importance Table used non-replacement sampling set of Conditional Inference trees to identify influential factors. Mean comparison tests compared LOS and op-time for top factors. 142 surgical CD patients (61 yrs, 62%F, 8.2 levels fused). Op-time and LOS were 358 min and 7.2 days; 30% of patients experienced E-LOS (14 ± 13 days). Overlapping predictors of E-LOS and op-time included levels fused (>7 increased LOS 2.7 days; >5 increased op-time 96 min, P < 0.001), approach (anterior reduced LOS 3.0 days; combined increased op-time 69 min, P < 0.01), BMI (>38 kg/m2 increased LOS 8.1 days; >39 kg/m2 increased op-time 17 min), and osteotomy (LOS 2.0 days, op-time 62 min, P < 0.005). BL cervical parameters increased LOS and op-time: cSVA (>42 mm increased LOS; >50 mm increased op-time, P < 0.030), C0 slope (>@-0.9° increased LOS, >0.3° increased op-time, P < 0.003.) Additional op-time predictors: prior cervical surgery (p = 0.004) and comorbidities (P = 0.015). Other predictors of E-LOS: EBL (P < 0.001), change in mental status (P = 0.001). Baseline cervical malalignment, levels fused, and osteotomy predicted both increased op-time and LOS. These results can be used to better optimize patient care, hospital efficiency, and resource allocation.

  View details for DOI 10.1016/j.jocn.2019.07.064

  View details for PubMedID 31402263

• Minimum five-year follow-up of posterior-only pedicle screw constructs for thoracic and thoracolumbar kyphosis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Hwang, C. J., Lenke, L. G., Kelly, M. P., Sides, B. A., Blanke, K. M., Hershman, S. 2019; 28 (11): 2609-2618

  Abstract

  Retrospective cohort study.To review/report 5-year follow-up data on patients diagnosed with thoracic and thoracolumbar kyphosis (TK/TLK) treated with posterior-only spinal fusion. TK/TLK was initially treated with combined anterior/posterior spinal fusion, evolving into widespread treatment with posterior-only spinal fusion.Forty-three patients who underwent a posterior-only spinal fusion for a primary diagnosis of TK/TLK from 1999 to 2009 with > 5-year follow-up were identified. Preoperative/postoperative/final follow-up measurements were recorded from full-length standing radiographs. Prospectively collected outcome scores were reviewed for the same time points, and charts were examined for complications.Patient age averaged 33 years (range 13-77), and follow-up averaged 5.6 years (range 5-12.2). Diagnoses included Scheuermann's disease (N = 15, 35%), idiopathic (N = 10, 23%), pseudarthrosis (N = 6, 14%), iatrogenic (N = 4, 9%), degenerative (N = 3, 7%), post-traumatic (N = 3, 7%), and congenital kyphosis (N = 2, 5%). Average correction of 44.3° (46%; 92.8° preoperatively vs 48.5° postoperatively) was achieved through posterior-only surgery. Loss of correction averaged only 1° in the instrumented segments at final follow-up. Eleven patients had a complication; proximal junctional kyphosis was the most common (N = 3, 7%). One patient lost intraoperative monitoring and one had temporary neurological deterioration postoperatively, but there was no permanent deficit. No pseudarthroses occurred. ODI scores improved 17.2 points on average (p = 0.01). SRS scores improved in all domains (average 0.79, p < 0.001).Pedicle screw constructs permit effective posterior-only correction of TK/TLK that is maintained at the 5-year follow-up time point. Patients report improvement, via outcome questionnaires, at the same follow-up time points. These slides can be retrieved under Electronic Supplementary Material.

  View details for DOI 10.1007/s00586-019-06076-0

  View details for PubMedID 31359215

• Development and validation of risk stratification models for adult spinal deformity surgery. Journal of neurosurgery. Spine Pellisé, F., Serra-Burriel, M., Smith, J. S., Haddad, S., Kelly, M. P., Vila-Casademunt, A., Sánchez Pérez-Grueso, F. J., Bess, S., Gum, J. L., Burton, D. C., Acaroğlu, E., Kleinstück, F., Lafage, V., Obeid, I., Schwab, F., Shaffrey, C. I., Alanay, A., Ames, C. 2019; 31 (4): 587-599

  Abstract

  Adult spinal deformity (ASD) surgery has a high rate of major complications (MCs). Public information about adverse outcomes is currently limited to registry average estimates. The object of this study was to assess the incidence of adverse events after ASD surgery, and to develop and validate a prognostic tool for the time-to-event risk of MC, hospital readmission (RA), and unplanned reoperation (RO).Two models per outcome, created with a random survival forest algorithm, were trained in an 80% random split and tested in the remaining 20%. Two independent prospective multicenter ASD databases, originating from the European continent and the United States, were queried, merged, and analyzed. ASD patients surgically treated by 57 surgeons at 23 sites in 5 countries in the period from 2008 to 2016 were included in the analysis.The final sample consisted of 1612 ASD patients: mean (standard deviation) age 56.7 (17.4) years, 76.6% women, 10.4 (4.3) fused vertebral levels, 55.1% of patients with pelvic fixation, 2047.9 observation-years. Kaplan-Meier estimates showed that 12.1% of patients had at least one MC at 10 days after surgery; 21.5%, at 90 days; and 36%, at 2 years. Discrimination, measured as the concordance statistic, was up to 71.7% (95% CI 68%-75%) in the development sample for the postoperative complications model. Surgical invasiveness, age, magnitude of deformity, and frailty were the strongest predictors of MCs. Individual cumulative risk estimates at 2 years ranged from 3.9% to 74.1% for MCs, from 3.17% to 44.2% for RAs, and from 2.67% to 51.9% for ROs.The creation of accurate prognostic models for the occurrence and timing of MCs, RAs, and ROs following ASD surgery is possible. The presented variability in patient risk profiles alongside the discrimination and calibration of the models highlights the potential benefits of obtaining time-to-event risk estimates for patients and clinicians.

  View details for DOI 10.3171/2019.3.SPINE181452

  View details for PubMedID 31252385

• Effect of Serious Adverse Events on Health-related Quality of Life Measures Following Surgery for Adult Symptomatic Lumbar Scoliosis. Spine Smith, J. S., Shaffrey, C. I., Kelly, M. P., Yanik, E. L., Lurie, J. D., Baldus, C. R., Edwards, C., Glassman, S. D., Lenke, L. G., Boachie-Adjei, O., Buchowski, J. M., Carreon, L. Y., Crawford, C. H., Errico, T. J., Lewis, S. J., Koski, T., Parent, S., Kim, H. J., Ames, C. P., Bess, S., Schwab, F. J., Bridwell, K. H. 2019; 44 (17): 1211-1219

  Abstract

  Secondary analysis of prospective multicenter cohort.To assess effect of serious adverse events (SAEs) on 2- and 4-year patient-reported outcomes measures (PROMs) in patients surgically treated for adult symptomatic lumbar scoliosis (ASLS).Operative treatment for ASLS can improve health-related quality of life, but has high rates of SAEs. How these SAEs effect health-related quality of life remain unclear.The ASLS study assessed operative versus nonoperative ASLS treatment, with randomized and observational arms. Patients were 40- to 80-years-old with ASLS, defined as lumbar coronal Cobb ≥30° and Oswestry Disability Index (ODI) ≥20 or Scoliosis Research Society-22 (SRS-22) ≤4.0 in pain, function, and/or self-image domains. SRS-22 subscore and ODI were compared between operative patients with and without a related SAE and nonoperative patients using an as-treated analysis combining randomized and observational cohorts.Two hundred eighty-six patients were enrolled, and 2- and 4-year follow-up rates were 90% and 81%, respectively, although at the time of data extraction not all patients were eligible for 4-year follow-up. A total of 97 SAEs were reported among 173 operatively treated patients. The most common were implant failure/pseudarthrosis (n = 25), proximal junctional kyphosis/failure (n = 10), and minor motor deficit (n = 8). At 2 years patients with an SAE improved less than those without an SAE based on SRS-22 (0.52 vs. 0.79, P = 0.004) and ODI (-11.59 vs. -17.34, P = 0.021). These differences were maintained at 4-years for both SRS-22 (0.51 vs. 0.86, P = 0.001) and ODI (-10.73 vs. -16.69, P = 0.012). Despite this effect, patients sustaining an operative SAE had greater PROM improvement than nonoperative patients (P<0.001).Patients affected by SAEs following surgery for ASLS had significantly less improvement of PROMs at 2- and 4-year follow-ups versus those without an SAE. Regardless of SAE occurrence, operatively treated patients had significantly greater improvement in PROMs than those treated nonoperatively.2.

  View details for DOI 10.1097/BRS.0000000000003036

  View details for PubMedID 30921297

  View details for PubMedCentralID PMC6697202

• Thoracolumbar junction orientation: its impact on thoracic kyphosis and sagittal alignment in both asymptomatic volunteers and symptomatic patients. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Moon, H. J., Bridwell, K. H., Theologis, A. A., Kelly, M. P., Lertudomphonwanit, T., Kim, H. J., Lenke, L. G., Gupta, M. C. 2019; 28 (9): 1937-1947

  Abstract

  The thoracolumbar junction (TLJ) has not been explored in regard to its contribution to global sagittal alignment. This study aims to define novel sagittal parameters of the TLJ and to assess their roles within global sagittal alignment.Included for cross-sectional, retrospective analysis were asymptomatic volunteers and symptomatic patients who had undergone operation for adult spinal deformity. Unique sagittal parameters of the TLJ were measured using the midline of the T12-L1 disk space: The TLJ orientation [TLJO; thoracolumbar tilt (TLT) and slope (TLS)]. Thoracic kyphosis (TK; T5-12), C7-S1 sagittal vertical axis (SVA), lumbar lordosis (LL; L1-S1), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured. Continuous variables were compared using the independent t test. Pearson correlations examined relationships between the parameters in each group. The asymptomatic TK was calculated using the measurement of the asymptomatic volunteer's TLJO by linear regression.One hundred fifteen asymptomatic volunteers and 127 symptomatic patients were included. Only LL among the lumbopelvic parameters correlated with TK (asymptomatic volunteers: r = - 0.42; symptomatic patients: r = - 0.40). All the pelvic parameters have no direct correlation with TK in both groups. TLJO had stronger correlation with TK [asymptomatic volunteers: r = - 0.68 (TLS), r = 0.41 (TLT); symptomatic patients: r = - 0.56 (TLS), r = 0.44 (TLT)] than the lumbopelvic parameters. TLS correlated with LL (asymptomatic volunteers: r = 0.78; symptomatic patients: r = 0.73). Most pelvic parameters correlated with TLJO except for PI. The asymptomatic TK was estimated by the derived formula: 20.847 + TLS × (- 1.198).The TLJO integrates the status of the lumbopelvic sagittal parameters and simultaneously correlates with thoracic and global sagittal alignment. These slides can be retrieved under Electronic Supplementary Material.

  View details for DOI 10.1007/s00586-019-06078-y

  View details for PubMedID 31342155

• Indicators for Nonroutine Discharge Following Cervical Deformity-Corrective Surgery: Radiographic, Surgical, and Patient-Related Factors. Neurosurgery Bortz, C. A., Passias, P. G., Segreto, F., Horn, S. R., Lafage, V., Smith, J. S., Line, B., Mundis, G. M., Kebaish, K. M., Kelly, M. P., Protopsaltis, T., Sciubba, D. M., Soroceanu, A., Klineberg, E. O., Burton, D. C., Hart, R. A., Schwab, F. J., Bess, S., Shaffrey, C. I., Ames, C. P. 2019; 85 (3): E509-E519

  Abstract

  Nonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost-of-care. Given the rising prevalence of cervical deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge.To identify factors associated with nonroutine discharge after CD-corrective surgery using a statistical learning algorithm.A retrospective review of patients ≥18 yr with discharge and baseline (BL) radiographic data. Conditional inference decision trees identified factors associated with nonroutine discharge and cut-off points at which factors were significantly associated with discharge status. A conditional variable importance table used nonreplacement sampling set of 10 000 conditional inference trees to identify influential patient/surgical factors. The binary logistic regression indicated odds of nonroutine discharge for patients with influential factors at significant cut-off points.Of 138 patients (61 yr, 63% female) undergoing surgery for CD (8 ± 5 levels; 49% posterior approach, 16% anterior, and 35% combined), 29% experienced nonroutine discharge. BL cervical/upper-cervical malalignment showed the strongest relationship with nonroutine discharge: C1 slope ≥ 14°, C2 slope ≥ 57°, TS-CL ≥ 57°. Patient-related factors associated with nonroutine discharge included BL gait impairment, age ≥ 59 yr and apex of CD primary driver ≥ C7. The only surgical factor associated with nonroutine discharge was fusion ≥ 8 levels. There was no relationship between nonhome discharge and reoperation within 6 mo or 1 yr (both P > .05) of index procedure. Despite no differences in BL EQ-5D (P = .946), nonroutine discharge patients had inferior 1-yr postoperative EQ-5D scores (P = .044).Severe preoperative cervical malalignment was strongly associated with nonroutine discharge following CD-corrective surgery. Age, deformity driver, and ≥ 8 level fusions were also associated with nonroutine discharge and should be taken into account to improve patient counseling and health care resource allocation.

  View details for DOI 10.1093/neuros/nyz016

  View details for PubMedID 30848284

• The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 2. Spine deformity Sethi, R. K., Burton, D. C., Wright, A. K., Lenke, L. G., Cerpa, M., Kelly, M. P., Daniels, A. H., Ames, C. P., Klineberg, E. O., Mundis, G. M., Bess, S., Hart, R. A. 2019; 7 (5): 684-695

  Abstract

  Structured literature review.To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery.Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies.We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications.Gaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care.Level II.

  View details for DOI 10.1016/j.jspd.2019.03.001

  View details for PubMedID 31495467

• The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 1. Spine deformity Burton, D. C., Sethi, R. K., Wright, A. K., Daniels, A. H., Ames, C. P., Reid, D. B., Klineberg, E. O., Harper, R., Mundis, G. M., Hlubek, R. J., Bess, S., Hart, R. A., Kelly, M. P., Lenke, L. G. 2019; 7 (5): 669-683

  Abstract

  Structured Literature Review.We sought to evaluate the peer-reviewed literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.Lean Methodology uses Standard Work to improve efficiency and decrease waste and error. ASD is known to have a high surgical complication rate. Several patient and surgical potentially modifiable factors have been suggested to affect complications, including preoperative hemoglobin, bone density, body mass index (BMI), age-appropriate realignment, preoperative albumin/prealbumin, and smoking status. We sought to evaluate the literature for evidence supporting these factors to include in a Standard Work protocol to decrease complications.Each of these six factors was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). A comprehensive literature search was then performed. The authors reviewed abstracts and analyzed data from included studies. From 456 initial citations with abstract, 173 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 93 included studies.We found fair evidence supporting a low preoperative hemoglobin level associated with increased transfusion rates and decreased BMD and increased BMI associated with increased complication rates. Fair evidence supported low albumin/prealbumin associated with increased complications. There was fair evidence associating smoking exposure to increased reoperations, but conflicting evidence associating it with increased complications. There was no evidence in the literature evaluating age-appropriate realignment and complications.Preoperative hemoglobin, bone density, body mass index, preoperative albumin/prealbumin, and smoking status all are potentially modifiable risk factors that are associated with increased complications in the adult spine surgery population. Developing a Standard Work Protocol for patient evaluation and optimization should include these factors.Level II.

  View details for DOI 10.1016/j.jspd.2019.04.003

  View details for PubMedID 31495466

• Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium. Journal of neurosurgery. Pediatrics Strahle, J. M., Taiwo, R., Averill, C., Torner, J., Shannon, C. N., Bonfield, C. M., Tuite, G. F., Bethel-Anderson, T., Rutlin, J., Brockmeyer, D. L., Wellons, J. C., Leonard, J. R., Mangano, F. T., Johnston, J. M., Shah, M. N., Iskandar, B. J., Tyler-Kabara, E. C., Daniels, D. J., Jackson, E. M., Grant, G. A., Couture, D. E., Adelson, P. D., Alden, T. D., Aldana, P. R., Anderson, R. C., Selden, N. R., Baird, L. C., Bierbrauer, K., Chern, J. J., Whitehead, W. E., Ellenbogen, R. G., Fuchs, H. E., Guillaume, D. J., Hankinson, T. C., Iantosca, M. R., Oakes, W. J., Keating, R. F., Khan, N. R., Muhlbauer, M. S., McComb, J. G., Menezes, A. H., Ragheb, J., Smith, J. L., Maher, C. O., Greene, S., Kelly, M., O'Neill, B. R., Krieger, M. D., Tamber, M., Durham, S. R., Olavarria, G., Stone, S. S., Kaufman, B. A., Heuer, G. G., Bauer, D. F., Albert, G., Greenfield, J. P., Wait, S. D., Van Poppel, M. D., Eskandari, R., Mapstone, T., Shimony, J. S., Dacey, R. G., Smyth, M. D., Park, T. S., Limbrick, D. D. 2019: 1–8

  Abstract

  OBJECTIVE: Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis.METHODS: A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°).RESULTS: Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude.CONCLUSIONS: Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.

  View details for DOI 10.3171/2019.5.PEDS18527

  View details for PubMedID 31419800

• Development of Deployable Predictive Models for Minimal Clinically Important Difference Achievement Across the Commonly Used Health-related Quality of Life Instruments in Adult Spinal Deformity Surgery. Spine Ames, C. P., Smith, J. S., Pellisé, F., Kelly, M. P., Gum, J. L., Alanay, A., Acaroğlu, E., Pérez-Grueso, F. J., Kleinstück, F. S., Obeid, I., Vila-Casademunt, A., Burton, D. C., Lafage, V., Schwab, F. J., Shaffrey, C. I., Bess, S., Serra-Burriel, M. 2019; 44 (16): 1144-1153

  Abstract

  Retrospective analysis of prospectively-collected, multicenter adult spinal deformity (ASD) databases.To predict the likelihood of reaching minimum clinically important differences in patient-reported outcomes after ASD surgery.ASD surgeries are costly procedures that do not always provide the desired benefit. In some series only 50% of patients achieve minimum clinically important differences in patient-reported outcomes (PROs). Predictive modeling may be useful in shared-decision making and surgical planning processes. The goal of this study was to model the probability of achieving minimum clinically important differences change in PROs at 1 and 2 years after surgery.Two prospective observational ASD cohorts were queried. Patients with Scoliosis Research Society-22, Oswestry Disability Index , and Short Form-36 data at preoperative baseline and at 1 and 2 years after surgery were included. Seventy-five variables were used in the training of the models including demographics, baseline PROs, and modifiable surgical parameters. Eight predictive algorithms were trained at four-time horizons: preoperative or postoperative baseline to 1 year and preoperative or postoperative baseline to 2 years. External validation was accomplished via an 80%/20% random split. Five-fold cross validation within the training sample was performed. Precision was measured as the mean average error (MAE) and R values.Five hundred seventy patients were included in the analysis. Models with the lowest MAE were selected; R values ranged from 20% to 45% and MAE ranged from 8% to 15% depending upon the predicted outcome. Patients with worse preoperative baseline PROs achieved the greatest mean improvements. Surgeon and site were not important components of the models, explaining little variance in the predicted 1- and 2-year PROs.We present an accurate and consistent way of predicting the probability for achieving clinically relevant improvement after ASD surgery in the largest-to-date prospective operative multicenter cohort with 2-year follow-up. This study has significant clinical implications for shared decision making, surgical planning, and postoperative counseling.4.

  View details for DOI 10.1097/BRS.0000000000003031

  View details for PubMedID 30896589

• Should Surgery for Adult Degenerative Lumbar Deformity be Staged? Clinical spine surgery Yu, H. H., Asuma, M. P., Wallace, C. S., Kelly, M. P., Kang, D. G. 2019; 32 (7): 269-271

  View details for DOI 10.1097/BSD.0000000000000775

  View details for PubMedID 30839421

• The minimum detectable measurement difference for the Scoliosis Research Society-22r in adolescent idiopathic scoliosis: a comparison with the minimum clinically important difference. The spine journal : official journal of the North American Spine Society Kelly, M. P., Lenke, L. G., Sponseller, P. D., Pahys, J. M., Bastrom, T. P., Lonner, B. S., Abel, M. F. 2019; 19 (8): 1319-1323

  Abstract

  The minimal clinically important difference (MCID) is the smallest change in an outcomes instrument deemed relevant to a patient. MCID values proposed in spine research are limited by poor discriminative abilities to accurately classify patients as "improved" or "not improved." Furthermore, the MCID should not compare relative effectiveness between two groups of patients, though it is frequently used for this. The minimum detectable measurement difference (MDMD) is an alternative to the MCID in outcomes research. The MDMD must be greater than the MCID for the latter to be of value and the MDMD can compare change between groups.The purpose of this study was to determine the MDMD for the Scoliosis Research Society-22r (SRS-22r) in adolescent idiopathic scoliosis (AIS) patients treated with surgery.Retrospective cohort study from multi-center registry.Patients treated surgically for AIS.Self-reported SRS-22r.An observational cohort of surgically treated AIS patients was queried for patients with complete baseline, 1-year, and 2-year SRS-22r data. The MDMD was calculated for SRS-22r domain and subscores. Effect size (ES) and standardized response mean were calculated to measure responsiveness of the SRS-22r to change. MDMD values were compared with MCID values. Research grants were received from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive, and Zimmer Biomet to Setting Scoliosis Straight Foundation.One thousand two hundred and eighty-one AIS patients (1,034 female, 247 male, mean age 14.6 years) were analyzed. MDMD values were between 0.23 and 0.31. SRS-Pain MDMD was 0.3, greater than the MCID of 0.2. SRS-Activity MDMD was 0.24, greater than the MCID of 0.08. SRS-self-image MDMD was 0.3, less than the MCID of 0.98. Sixty-four percent of those with baseline SRS-self-image>4.0 improved MDMD or more, whereas only 14% improved beyond the MCID. ES and standardized response mean were highest for subscore and self-image.The MDMD can compare the relevance of change in SRS-22r scores between groups of AIS patients. SRS-pain and SRS-activity MDMD values are greater than the MCID and should serve as the threshold for clinically relevant improvement. MDMD may help evaluate change in patients with baseline self-image>4.0.

  View details for DOI 10.1016/j.spinee.2019.04.008

  View details for PubMedID 30986576

• Grading of Complications After Cervical Deformity-corrective Surgery: Are Existing Classification Systems Applicable? Clinical spine surgery Bortz, C. A., Passias, P. G., Segreto, F. A., Horn, S. R., Lafage, R., Smith, J. S., Line, B. G., Mundis, G. M., Kelly, M. P., Park, P., Sciubba, D. M., Hamilton, D. K., Gum, J. L., Burton, D. C., Hart, R. A., Schwab, F. J., Bess, S., Shaffrey, C., Klineberg, E. O. 2019; 32 (6): 263-268

  Abstract

  This is a retrospective review of prospective multicenter cervical deformity (CD) database.Assess the impact of complication type and Clavien complication (Cc) grade on clinical outcomes of surgical CD patients BACKGROUND:: Validated for general surgery, the Clavien-Dindo complication classification system allows for broad comparison of postoperative complications; however, the applicability of this system is unclear in CD-specific populations.Surgical CD patients above 18 years with baseline and postoperative clinical data were included. Primary outcomes were complication type (renal, infection, cardiac, pulmonary, gastrointestinal, neurological, musculoskeletal, implant-related, radiographic, operative, wound) and Cc grade (I, II, III, IV, V). Secondary outcomes were estimated blood loss (EBL), length of stay (LOS), reoperation, and health-related quality of life (HRQL) score. The univariate analysis assessed the impact of complication type and Cc grade on improvement markers and 1-year postoperative HRQL outcomes.In total, 153 patients (61±10 y, 61% female) underwent surgery for CD (8.1±4.6 levels fused; surgical approach included 48% posterior, 18% anterior, 34% combined). Overall, 63% of patients suffered at least 1 complication. Complication breakdown by type: renal (2.0%), infection (5.2%), cardiac (7.2%), pulmonary (3.9%), gastrointestinal (2.0%), neurological (26.1%), musculoskeletal (0.0%), implant-related (3.9%), radiographic (16.3%), operative (7.8%), and wound (5.2%). Of complication types, only operative complications were associated with increased EBL (P=0.004), whereas renal, cardiac, pulmonary, gastrointestinal, neurological, radiographic, and wound infections were associated with increased LOS (P<0.050). Patients were also assessed by Cc grade: I (28%), II (14.3%), III (16.3%), IV (6.5%), and V (0.7%). Grades I and V were associated with increased EBL (both P<0.050); Cc grade V was the only complication not associated with increased LOS (P=0.610). Increasing complication severity was correlated with increased risk of reoperation (r=0.512; P<0.001), but not inferior 1-year HRQL outcomes (all P>0.05).Increasing complication severity, assessed by the Clavien-Dindo classification system, was not associated with increased EBL, inpatient LOS, or inferior 1-year postoperative HRQL outcomes. Only operative complications were associated with increased EBL. These results suggest a need for modification of the Clavien system to increase applicability and utility in CD-specific populations.

  View details for DOI 10.1097/BSD.0000000000000748

  View details for PubMedID 30451785

• Artificial Intelligence Based Hierarchical Clustering of Patient Types and Intervention Categories in Adult Spinal Deformity Surgery: Towards a New Classification Scheme that Predicts Quality and Value. Spine Ames, C. P., Smith, J. S., Pellisé, F., Kelly, M., Alanay, A., Acaroğlu, E., Pérez-Grueso, F. J., Kleinstück, F., Obeid, I., Vila-Casademunt, A., Shaffrey, C. I., Burton, D., Lafage, V., Schwab, F., Shaffrey, C. I., Bess, S., Serra-Burriel, M. 2019; 44 (13): 915-926

  Abstract

  Retrospective review of prospectively-collected, multicenter adult spinal deformity (ASD) databases.To apply artificial intelligence (AI)-based hierarchical clustering as a step toward a classification scheme that optimizes overall quality, value, and safety for ASD surgery.Prior ASD classifications have focused on radiographic parameters associated with patient reported outcomes. Recent work suggests there are many other impactful preoperative data points. However, the ability to segregate patient patterns manually based on hundreds of data points is beyond practical application for surgeons. Unsupervised machine-based clustering of patient types alongside surgical options may simplify analysis of ASD patient types, procedures, and outcomes.Two prospective cohorts were queried for surgical ASD patients with baseline, 1-year, and 2-year SRS-22/Oswestry Disability Index/SF-36v2 data. Two dendrograms were fitted, one with surgical features and one with patient characteristics. Both were built with Ward distances and optimized with the gap method. For each possible n patient cluster by m surgery, normalized 2-year improvement and major complication rates were computed.Five hundred-seventy patients were included. Three optimal patient types were identified: young with coronal plane deformity (YC, n = 195), older with prior spine surgeries (ORev, n = 157), and older without prior spine surgeries (OPrim, n = 218). Osteotomy type, instrumentation and interbody fusion were combined to define four surgical clusters. The intersection of patient-based and surgery-based clusters yielded 12 subgroups, with major complication rates ranging from 0% to 51.8% and 2-year normalized improvement ranging from -0.1% for SF36v2 MCS in cluster [1,3] to 100.2% for SRS self-image score in cluster [2,1].Unsupervised hierarchical clustering can identify data patterns that may augment preoperative decision-making through construction of a 2-year risk-benefit grid. In addition to creating a novel AI-based ASD classification, pattern identification may facilitate treatment optimization by educating surgeons on which treatment patterns yield optimal improvement with lowest risk.4.

  View details for DOI 10.1097/BRS.0000000000002974

  View details for PubMedID 31205167

• Cervical and Cervicothoracic Sagittal Alignment According to Roussouly Thoracolumbar Subtypes. Spine Theologis, A. A., Iyer, S., Lenke, L. G., Sides, B. A., Kim, H. J., Kelly, M. P. 2019; 44 (11): E634-E639

  Abstract

  Cross-sectional cohort.To determine normative radiographic sagittal cervical alignment in asymptomatic volunteers based on Roussouly thoracolumbar sagittal alignment subtypes.Comprehension of differences in cervicothoracic alignment with respect to variations in thoracolumbar alignment is limited.Asymptomatic adults were recruited and the following parameters measured: PI, PT, SS, LL, orbital tilt, orbital slope, occipital slope and incidence, occiput-C2 lordosis, C2-7 lordosis, occiput-C7 lordosis, CBVA, T1 slope, cervicothoracic alignment, T2-5 kyphosis, and C2-C7 sagittal vertebral alignment (SVA). Each was classified into one of Roussouly's four thoracolumbar subtypes and cervical alignment parameters were compared between groups.Eighty-seven individuals [male-23; female-64; average age 49 ± 16 yr (22-77 yr)] were included for analysis. The four groups were not different by age, sex, and body mass index (BMI). Lumbopelvic parameters (PI, SS, PT, LL) were different between Roussouly types. Average values for all patients included: CBVA (-1 ± 9°), occiput-C2 lordosis (28 ± 9°), occiput-C7 lordosis (39 ± 14°), C2-7 lordosis (11 ± 14°), C2-7 SVA (21 ± 9 mm), T1 slope (25 ± 9°), C6-T4 angle (5 ± 8°), T2-5 angle (16 ± 7°), thoracic kyphosis (47 ± 13°). No sagittal radiographic alignment measurements of the cervical spine and cervicothoracic junction were different between groups, except for the global cervical lordosis (occiput-C7 Cobb), which was found to be lowest for Roussouly type 2 (35 ± 14°) and highest for type 4 (48 ± 14°) (P = 0.01). Mean C2-C7 sagittal Cobb, T2-T5 sagittal Cobb, and T1 slope were not different between groups.In asymptomatic volunteers, normative sagittal alignment parameters of the cervical spine, cervicothoracic junction, and thoracic spine based on variations in thoracolumbar sagittal alignment, as proposed by Roussouly, are established. These data may guide surgical correction of cervicothoracic deformities to ensure appropriate restoration of normal cervicothoracic parameters to maintain good horizontal gaze and overall sagittal plane alignment.3.

  View details for DOI 10.1097/BRS.0000000000002941

  View details for PubMedID 30475347

• Examining the Patient-Reported Outcomes Measurement Information System versus the Scoliosis Research Society-22r in adult spinal deformity. Journal of neurosurgery. Spine Kelly, M. P., Kallen, M. A., Shaffrey, C. I., Smith, J. S., Burton, D. C., Ames, C. P., Lafage, V., Schwab, F. J., Kim, H. J., Klineberg, E. O., Bess, S. 2019; 30 (6): 801-806

  Abstract

  After using PROsetta Stone crosswalk tables to calculate Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores, the authors sought to examine 1) correlations with Scoliosis Research Society-22r (SRS-22r) scores, 2) responsiveness to change, and 3) the relationship between baseline scores and 2-year follow-up scores in adult spinal deformity (ASD).PROsetta Stone crosswalk tables were used to converted SF-36 scores to PROMIS scores for pain and physical function in a cohort of ASD patients with 2-year follow-up. Spearman correlations were used to evaluate the relationship of PROMIS scores with SRS-22r scores. Effect size (ES) and adjusted standardized response mean (aSRM) were used to assess responsiveness to change. Linear regression was used to evaluate the association between baseline scores and 2-year follow-up scores.In total, 425 (425/625, 68%) patients met inclusion criteria. Strong correlations (all |r| > 0.7, p < 0.001) were found between baseline and 2-year PROMIS values and corresponding SRS-22r domain scores. PROMIS-PI showed a large ES (1.09) and aSRM (0.88), indicating good responsiveness to change. PROMIS-PF showed a moderate ES (0.52) and moderate aSRM (0.69), indicating a moderate responsiveness to change. Patients with greater baseline pain complaints were associated with greater pain improvement at 2 years for both SRS-22r Pain (B = 0.39, p < 0.001) and PROMIS-PI (B = 0.45, p < 0.001). Higher functional scores at baseline were associated with greater average improvements in both SRS-22r Activity (B = 0.62, p < 0.001) and PROMIS-PF (B = 0.40, p < 0.001).The authors found strong correlations between the SRS-22r Pain and Activity domains with corresponding PROMIS-PI and -PF scores. Pain measurements showed similar and strong ES and aSRM while the function measurements showed similar, moderate ES and aSRM at 2-year follow-up. These data support further exploration of the use of PROMIS-computer adaptive test instruments in ASD.

  View details for DOI 10.3171/2018.11.SPINE181014

  View details for PubMedID 30797200

• Comparison of Single-Level Versus Multilevel Vertebral Column Resection Surgery for Pediatric Patients With Severe Spinal Deformities. Spine Hwang, C. J., Lenke, L. G., Sides, B. A., Blanke, K. M., Kelly, M. P. 2019; 44 (11): E664-E670

  Abstract

  Retrospective cohort of pediatric patients (younger than 21 years) with severe spinal deformities who underwent vertebral column resection (VCR) surgery.To compare patients who underwent single- versus multilevel VCR surgery in terms of radiographic correction and perioperative complications.There are few studies comparing single- to multilevel VCR surgery regarding the efficacy and safety of the procedures.Eighty-two pediatric patients who underwent a VCR for severe spinal deformity between 2002 and 2012 by one surgeon were included. A single-level VCR was performed in 45 patients with an average of 4.7-year follow-up, and multilevel VCR in 37 patients with an average of 4.6-year follow-up.Coronal Cobb corrections were not different between groups (single level: 63%, multilevel: 58%, P = 0.146). Correction loss at final follow-up did not differ (3.1° vs. 0.3°, P = 0.132). Patients in the single-level group had shorter operation times (9.2 vs. 10.5 hours, P = 0.046), whereas estimated blood loss did not differ between the two groups (1061 vs. 1200 mL, P = 0.181). The rate of spinal cord monitoring events was 20% (8/40) and 30% (9/30), respectively. No patient in the single-level group had a postoperative neurologic deficit, whereas three patients in the multilevel group experienced a temporary deficit postoperatively (0/45 vs. 3/37, P = 0.088).There was no difference in radiographic correction between the single- and multilevel VCR groups. The multilevel VCR patients had longer operative times, and although the differences were not statistically significant due to low sample size, the multilevel VCR group also had an increased rate of postoperative neurologic deficits. We would recommend single-level VCRs unless there is an absolute indication for multilevel resection as in necessary decompression for spinal cord impingement.4.

  View details for DOI 10.1097/BRS.0000000000002948

  View details for PubMedID 30475336

• Evolution in Surgical Approach, Complications, and Outcomes in an Adult Spinal Deformity Surgery Multicenter Study Group Patient Population. Spine deformity Daniels, A. H., Reid, D. B., Tran, S. N., Hart, R. A., Klineberg, E. O., Bess, S., Burton, D., Smith, J. S., Shaffrey, C., Gupta, M., Ames, C. P., Hamilton, D. K., LaFage, V., Schwab, F., Eastlack, R., Akbarnia, B., Kim, H. J., Kelly, M., Passias, P. G., Protopsaltis, T., Mundis, G. M. 2019; 7 (3): 481-488

  Abstract

  Retrospective review of a prospectively collected multicenter database.To evaluate the evolution of surgical treatment strategies, complications, and patient-reported outcomes for adult spinal deformity (ASD) patients.ASD surgery is associated with high complication rates. Evolving treatment strategies may reduce these risks.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.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).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 IV.

  View details for DOI 10.1016/j.jspd.2018.09.013

  View details for PubMedID 31053319

• Comparison of Best Versus Worst Clinical Outcomes for Adult Cervical Deformity Surgery GLOBAL SPINE JOURNAL Smith, J. S., Shaffrey, C. I., Kim, H., Passias, P., Protopsaltis, T., Lafage, R., Mundis, G. M., Klineberg, E., Lafage, V., Schwab, F. J., Scheer, J. K., Kelly, M., Hamilton, D., Gupta, M., Deviren, V., Hostin, R., Albert, T., Riew, K., Hart, R., Burton, D., Bess, S., Ames, C. P., Int Spine Study Grp 2019; 9 (3): 303-314

  Abstract

  Retrospective cohort study.Factors that predict outcomes for adult cervical spine deformity (ACSD) have not been well defined. To compare ACSD patients with best versus worst outcomes.This study was based on a prospective, multicenter observational ACSD cohort. Best versus worst outcomes were compared based on Neck Disability Index (NDI), Neck Pain Numeric Rating Scale (NP-NRS), and modified Japanese Orthopaedic Association (mJOA) scores.Of 111 patients, 80 (72%) had minimum 1-year follow-up. For NDI, compared with best outcome patients (n = 28), worst outcome patients (n = 32) were more likely to have had a major complication (P = .004) and to have undergone a posterior-only procedure (P = .039), had greater Charlson Comorbidity Index (P = .009), and had worse postoperative C7-S1 sagittal vertical axis (SVA; P = .027). For NP-NRS, compared with best outcome patients (n = 26), worst outcome patients (n = 18) were younger (P = .045), had worse baseline NP-NRS (P = .034), and were more likely to have had a minor complication (P = .030). For the mJOA, compared with best outcome patients (n = 16), worst outcome patients (n = 18) were more likely to have had a major complication (P = .007) and to have a better baseline mJOA (P = .030). Multivariate models for NDI included posterior-only surgery (P = .006), major complication (P = .002), and postoperative C7-S1 SVA (P = .012); models for NP-NRS included baseline NP-NRS (P = .009), age (P = .017), and posterior-only surgery (P = .038); and models for mJOA included major complication (P = .008).Factors distinguishing best and worst ACSD surgery outcomes included patient, surgical, and radiographic factors. These findings suggest areas that may warrant greater awareness to optimize patient counseling and outcomes.

  View details for DOI 10.1177/2192568218794164

  View details for Web of Science ID 000474173000010

  View details for PubMedID 31192099

  View details for PubMedCentralID PMC6542159

• Cost-Utility Analysis of Operative Versus Nonoperative Treatment of Thoracic Adolescent Idiopathic Scoliosis. Spine Jain, A., Marks, M. C., Kelly, M. P., Lenke, L. G., Errico, T. J., Lonner, B. S., Newton, P. O., Sponseller, P. D. 2019; 44 (5): 309-317

  Abstract

  Cost-utility analysis OBJECTIVE.: To compare the cost utility of operative versus nonoperative treatment of adolescent idiopathic scoliosis (AIS) and identity factors that influence cost-utility estimates.AIS affects 1% to 3% of children aged 10 to 16 years. When the major coronal curve reaches 50°, operative treatment may be considered. The cost utility of operative treatment of AIS is unknown.A decision-analysis model comparing operative versus nonoperative treatment was developed for a hypothetical 15-year-old skeletally mature girl with a 55° right thoracic (Lenke 1) curve. The AIS literature was reviewed to estimate the probability, health utility, and quality-adjusted life years (QALYs) for each event. For the conservative model, we assumed that operative treatment did not result directly in any QALYs gained, and the health utility in AIS patients was the same as the age-matched US population mean. Costs were inflation-adjusted at 3.22% per year to 2015 US dollars. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates.Operative treatment was favored in 98.5% of simulations, with a median ICUR of $20,600/QALY (95% confidence interval, $20,500-$21,900) below the societal willingness-to-pay threshold (WTPT) of $50,000/QALY. The median incremental net monetary benefit associated with operative treatment was $15,100 (95% confidence interval, $14,800-$15,700). Operative treatment produced net monetary benefit across various WTPTs. Factors that most affected the ICUR were net costs associated with uncomplicated operative treatment, undergoing surgery during adulthood, and development of pulmonary complications.Cost-utility analysis suggests that operative treatment of AIS is favored over nonoperative treatment and falls below the $50,000/QALY WTPT for patients with Lenke 1 curves.2.

  View details for DOI 10.1097/BRS.0000000000002936

  View details for PubMedID 30475341

• Operative Versus Nonoperative Treatment for Adult Symptomatic Lumbar Scoliosis JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kelly, M. P., Lurie, J. D., Yanik, E. L., Shaffrey, C. I., Baldus, C. R., Boachie-Adjei, O., Buchowski, J. M., Carreon, L. Y., Crawford, C. H., Edwards, C., Errico, T. J., Glassman, S. D., Gupta, M. C., Lenke, L. G., Lewis, S. J., Kim, H., Koski, T., Parent, S., Schwab, F. J., Smith, J. S., Zebala, L. P., Bridwell, K. H. 2019; 101 (4): 338-352

  Abstract

  The effectiveness of operative compared with nonoperative treatment at initial presentation (no prior fusion) for adult lumbar scoliosis has not, to our knowledge, been evaluated in controlled trials. The goals of this study were to evaluate the effects of operative and nonoperative treatment and to assess the benefits of these treatments to help treating physicians determine whether patients are better managed operatively or nonoperatively.Patients with adult symptomatic lumbar scoliosis (aged 40 to 80 years, with a coronal Cobb angle measurement of ≥30° and an Oswestry Disability Index [ODI] score of ≥20 or Scoliosis Research Society [SRS]-22 score of ≤4.0) from 9 North American centers were enrolled in concurrent randomized or observational cohorts to evaluate operative versus nonoperative treatment. The primary outcomes were differences in the mean change from baseline in the SRS-22 subscore and ODI at 2-year follow-up. For the randomized cohort, the initial sample-size calculation estimated that 41 patients per group (82 total) would provide 80% power with alpha equal to 0.05, anticipating 10% loss to follow-up and 20% nonadherence in the nonoperative arm. However, an interim sample-size calculation estimated that 18 patients per group would be sufficient.Sixty-three patients were enrolled in the randomized cohort: 30 in the operative group and 33 in the nonoperative group. Two hundred and twenty-three patients were enrolled in the observational cohort: 112 in the operative group and 111 in the nonoperative group. The intention-to-treat analysis of the randomized cohort found that, at 2 years of follow-up, outcomes did not differ between the groups. Nonadherence was high in the randomized cohort (64% nonoperative-to-operative crossover). In the as-treated analysis of the randomized cohort, operative treatment was associated with greater improvement at the 2-year follow-up in the SRS-22 subscore (adjusted mean difference, 0.7 [95% confidence interval (CI), 0.5 to 1.0]) and in the ODI (adjusted mean difference, -16 [95% CI, -22 to -10]) (p < 0.001 for both). Surgery was also superior to nonoperative care in the observational cohort at 2 years after treatment on the basis of SRS-22 subscore and ODI outcomes (p < 0.001). In an overall responder analysis, more operative patients achieved improvement meeting or exceeding the minimal clinically important difference (MCID) in the SRS-22 subscore (85.7% versus 38.7%; p < 0.001) and the ODI (77.4% versus 38.3%; p < 0.001). Thirty-four revision surgeries were performed in 24 (14%) of the operative patients.On the basis of as-treated and MCID analyses, if a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely. If a patient is not satisfied with current spine health and expects improvement, surgery is preferred.Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.18.00483

  View details for Web of Science ID 000460427300012

  View details for PubMedID 30801373

  View details for PubMedCentralID PMC6738555

• Surgery for the Adolescent Idiopathic Scoliosis Patients After Skeletal Maturity: Early Versus Late Surgery. Spine deformity Lonner, B. S., Ren, Y., Bess, S., Kelly, M., Kim, H. J., Yaszay, B., Lafage, V., Marks, M., Miyanji, F., Shaffrey, C. I., Newton, P. O. 2019; 7 (1): 84-92

  Abstract

  Informed decision making for operative treatment of the skeletally mature adolescent idiopathic scoliosis (AIS) patient meeting surgical indications requires a discussion of differences in operative morbidity in adult scoliosis versus AIS. This study evaluated differences in operative data and outcomes between AIS and adult scoliosis patients based on an estimated natural history of curve progression.Twenty-eight adult scoliosis patients (43.7 ± 15.8 years; 93% F) were 1:2 matched with 56 (Risser 4/5) AIS patients (15.7 ± 2.1 years) based on gender and curve type as vetted by 5 surgeons' consensus in committee. Curve progression of 0.3°/year for the first 10 years following skeletal maturity and a 0.5°/year thereafter was assumed to estimate curve progression from AIS to adulthood for the adult counterpart. Operative data, complications, and quality of life (Scoliosis Research Society [SRS-22r] questionnaire) measures were evaluated, with a minimum 2-year follow-up.Postoperative major Cobb and percentage correction were similar between adult versus AIS, whereas operative time, percentage estimated blood loss (EBL; % total blood volume), length of hospital stay (LOS), and total spine levels fused were greater for adult patients (p < .05). No difference was found in EBL, operative time, or LOS when normalized by levels fused. Ten (36%) adult scoliosis patients were fused to the pelvis compared with none in AIS (p < .0001). Major complication rate was higher for adult versus AIS (25% vs. 5.4%; p < .05). Preoperative SRS-22r scores were worse for adult patients; however, they demonstrated greater improvement in SRS-22r than the AIS cohort at final follow-up. A higher percentage of adult patients reached the MCID in self-image domain than the AIS patients (92.3% vs. 61.8%; p = .0040).Treatment of the adult scoliosis patient who has undergone an estimated natural history of progression is characterized by greater levels fused, operative time, and higher complication rates than the AIS counterpart. Longer-term follow-up of AIS is needed to define the benefits of early intervention of relatively asymptomatic adolescent patients versus late treatment of symptomatic disease in the adult.

  View details for DOI 10.1016/j.jspd.2018.05.012

  View details for PubMedID 30587326

• Major Complications at Two Years After Surgery Impact SRS Scores for Adolescent Idiopathic Scoliosis Patients. Spine deformity Bastrom, T. P., Yaszay, B., Shah, S. A., Miyanji, F., Lonner, B. S., Kelly, M. P., Samdani, A., Asghar, J., Newton, P. O. 2019; 7 (1): 93-99

  Abstract

  Retrospective review of prospectively collected data.To determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores.There is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients.Surgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated.1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p < .05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p < .05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p < .001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10).When timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score.Level III.

  View details for DOI 10.1016/j.jspd.2018.05.009

  View details for PubMedID 30587327

• Considering Spine Surgery: A Web-Based Calculator for Communicating Estimates of Personalized Treatment Outcomes. Spine Moulton, H., Tosteson, T. D., Zhao, W., Pearson, L., Mycek, K., Scherer, E., Weinstein, J. N., Pearson, A., Abdu, W., Schwarz, S., Kelly, M., McGuire, K., Milam, A., Lurie, J. D. 2018; 43 (24): 1731-1738

  Abstract

  Prospective evaluation of an informational web-based calculator for communicating estimates of personalized treatment outcomes.To evaluate the usability, effectiveness in communicating benefits and risks, and impact on decision quality of a calculator tool for patients with intervertebral disc herniations, spinal stenosis, and degenerative spondylolisthesis who are deciding between surgical and nonsurgical treatments.The decision to have back surgery is preference-sensitive and warrants shared decision making. However, more patient-specific, individualized tools for presenting clinical evidence on treatment outcomes are needed.Using Spine Patient Outcomes Research Trial data, prediction models were designed and integrated into a web-based calculator tool: http://spinesurgerycalc.dartmouth.edu/calc/. Consumer Reports subscribers with back-related pain were invited to use the calculator via email, and patient participants were recruited to use the calculator in a prospective manner following an initial appointment at participating spine centers. Participants completed questionnaires before and after using the calculator. We randomly assigned previously validated questions that tested knowledge about the treatment options to be asked either before or after viewing the calculator.A total of 1256 consumer reports subscribers and 68 patient participants completed the calculator and questionnaires. Knowledge scores were higher in the postcalculator group compared to the precalculator group, indicating that calculator usage successfully informed users. Decisional conflict was lower when measured following calculator use, suggesting the calculator was beneficial in the decision-making process. Participants generally found the tool helpful and easy to use.Although the calculator is not a comprehensive decision aid, it does focus on communicating individualized risks and benefits for treatment options. Moreover, it appears to be helpful in achieving the goals of more traditional shared decision-making tools. It not only improved knowledge scores but also improved other aspects of decision quality.2.

  View details for DOI 10.1097/BRS.0000000000002723

  View details for PubMedID 29877995

  View details for PubMedCentralID PMC6279474

• Prospective Multicenter Assessment of All-Cause Mortality Following Surgery for Adult Cervical Deformity NEUROSURGERY Smith, J. S., Shaffrey, C. I., Kim, H., Passias, P., Protopsaltis, T., Lafage, R., Mundis, G. M., Klineberg, E., Lafage, V., Schwab, F. J., Scheer, J. K., Miller, E., Kelly, M., Hamilton, D., Gupta, M., Deviren, V., Hostin, R., Albert, T., Riew, K., Hart, R., Burton, D., Bess, S., Ames, C. P., Int Spine Study Grp 2018; 83 (6): 1277–85

  Abstract

  Surgical treatments for adult cervical spinal deformity (ACSD) are often complex and have high complication rates.To assess all-cause mortality following ACSD surgery.ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Clinical and surgical parameters and all-cause mortality were assessed.Of 123 ACSD patients, 120 (98%) had complete baseline data (mean age, 60.6 yr). The mean number of comorbidities per patient was 1.80, and 80% had at least 1 comorbidity. Surgical approaches included anterior only (15.8%), posterior only (50.0%), and combined anterior/posterior (34.2%). The mean number of vertebral levels fused was 8.0 (standard deviation [SD] = 4.5), and 23.3% had a 3-column osteotomy. Death was reported for 11 (9.2%) patients at a mean of 1.1 yr (SD = 0.76 yr; range = 7 d to 2 yr). Mean follow-up for living patients was 1.2 yr (SD = 0.64 yr). Causes of death included myocardial infarction (n = 2), pneumonia/cardiopulmonary failure (n = 2), sepsis (n = 1), obstructive sleep apnea/narcotics (n = 1), subsequently diagnosed amyotrophic lateral sclerosis (n = 1), burn injury related to home supplemental oxygen (n = 1), and unknown (n = 3). Deceased patients did not significantly differ from alive patients based on demographic, clinical, or surgical parameters assessed, except for a higher major complication rate (excluding mortality; 63.6% vs 22.0%, P = .006).All-cause mortality at a mean of 1.2 yr following surgery for ACSD was 9.2% in this prospective multicenter series. Causes of death were reflective of the overall high level of comorbidities. These findings may prove useful for treatment decision making and patient counseling in the context of the substantial impact of ACSD.

  View details for PubMedID 29351637

• Anxiety in the orthopedic patient: using PROMIS to assess mental health. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Beleckas, C. M., Prather, H., Guattery, J., Wright, M., Kelly, M., Calfee, R. P. 2018; 27 (9): 2275-2282

  Abstract

  This study explored the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety assessment relative to the Depression assessment in orthopedic patients, the relationship between Anxiety with self-reported Physical Function and Pain Interference, and to determine if Anxiety levels varied according to the location of orthopedic conditions.This cross-sectional evaluation analyzed 14,962 consecutive adult new-patient visits to a tertiary orthopedic practice between 4/1/2016 and 12/31/2016. All patients completed PROMIS Anxiety, Depression, Physical Function, and Pain Interference computer adaptive tests (CATs) as routine clinical intake. Patients were grouped by the orthopedic service providing care and categorized as either affected with Anxiety if scoring > 62 based on linkage to the Generalized Anxiety Disorder-7 survey. Spearman correlations between the PROMIS scores were calculated. Bivariate statistics assessed differences in Anxiety and Depression scores between patients of different orthopedic services.20% of patients scored above the threshold to be considered affected by Anxiety. PROMIS Anxiety scores demonstrated a stronger correlation than Depression scores with Physical Function and Pain Interference scores. Patients with spine conditions reported the highest median Anxiety scores and were more likely to exceed the Anxiety threshold than patients presenting to sports or upper extremity surgeons.One in five new orthopedic patients reports Anxiety levels that may warrant intervention. This rate is heightened in patients needing spine care. Patient-reported Physical Function more strongly correlates with PROMIS Anxiety than Depression suggesting that the Anxiety CAT is a valuable addition to assess mental health among orthopedic patients.Diagnostic level III.

  View details for DOI 10.1007/s11136-018-1867-7

  View details for PubMedID 29740783

  View details for PubMedCentralID PMC6222016

• Rod fracture in adult spinal deformity surgery fused to the sacrum: prevalence, risk factors, and impact on health-related quality of life in 526 patients SPINE JOURNAL Lertudomphonwanit, T., Kelly, M. P., Bridwell, K. H., Lenke, L. G., McAnany, S. J., Punyarat, P., Bryan, T. P., Buchowski, J. M., Zebala, L. P., Sides, B. A., Steger-May, K., Gupta, M. C. 2018; 18 (9): 1612-1624

  Abstract

  Risk factors associated with rod fracture (RF) following adult spinal deformity (ASD) surgery fused to the sacrum remain debatable, and the impact of RF on patient-reported outcomes (PROs) after ASD surgery has not been investigated.We aimed to evaluate the prevalence of and risk factors for RF and determine PROs changes associated with RF after ASD surgery fused to the sacrum.A retrospective single-center cohort study was performed.Patients undergoing long-construct posterior spinal fusions to the sacrum performed at a single institution by two senior spine surgeons from 2004 to 2014 were included.Patient demographics, radiographic parameters, and surgical factors were assessed for risk factors associated with RF. Oswestry Disability Index (ODI) and Scoliosis Research Society-30 (SRS-30) scores were assessed at baseline, 1 year postoperatively, and latest follow-up.Inclusion criteria were ASD patients age >18 who had ≥5 vertebrae instrumented and fused posteriorly to the sacrum and either development of RF or no development of RF with minimum 2-year follow-up. Patient characteristics, operative data, radiographic parameters, and PROs were analyzed at baseline and follow-up. Separate Cox proportional hazard models based on rod material and diameter were used to determine factors associated with RF.Five hundred twenty-six patients (80%) were available for analysis. RF occurred in 97 (18.4%) patients (unilateral RF n=61 [63%]; bilateral RF n=36 [37%]). Risk factors for fracture of 5.5 mm cobalt chromium (CC) instrumentation (CC 5.5 model) included preoperative sagittal vertical axis (hazard ratio [HR] 1.07, 95% confidence interval [95% CI] 1.02-1.14 per 1-cm increase), preoperative thoracolumbar kyphosis (HR 1.02, 95% CI 1.01-1.04 per 1-degree increase), and number of levels fused for patients who received rhBMP-2 <12 mg per level fused (HR 1.48, 95% CI 1.20-1.82 per 1-level increase). Implants that were 5.5-mm CC constructs were at a higher risk for fracture than 6.35-mm stainless steel (SS) constructs (HR 8.49, 95% CI 4.26-16.89). The RF group had less overall improvement in SRS Satisfaction (0.93 vs. 1.32; p=.007) and SRS Self-image domain scores (0.72 vs. 1.02; p=.01). The bilateral RF group had less overall improvement in ODI (8.1 vs. 15.8; p=.02), SRS Subscore (0.51 vs. 0.85; p=.03), and SRS Pain domain scores (0.48 vs. 0.95; p=.02) compared with the non-RF group at final follow-up.The prevalence of all RF after index procedures was 18.4%, 37% for bilateral RF. Greater preoperative sagittal vertical axis, greater preoperative thoracolumbar kyphosis, increased number of vertebrae fused for patients who received rhBMP-2 <12 mg per level fused, and CC 5.5-mm rod were associated with RF. Less improvement in patient satisfaction and self-image was noted in the RF group. Furthermore, bilateral RF significantly affected PROs as measured by ODI and SRS Subscore at final follow-up.

  View details for DOI 10.1016/j.spinee.2018.02.008

  View details for Web of Science ID 000445024600013

  View details for PubMedID 29501749

• Cost-utility analysis of cervical deformity surgeries using 1-year outcome SPINE JOURNAL Poorman, G. W., Passias, P. G., Qureshi, R., Hassanzadeh, H., Horn, S., Bortz, C., Segreto, F., Jain, A., Kelly, M., Hostin, R., Ames, C., Smith, J., LaFage, V., Burton, D., Bess, S., Shaffrey, C., Schwab, F., Gupta, M. 2018; 18 (9): 1552-1557

  Abstract

  Cost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction.This is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2-C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2-C7 sagittal vertical axis >4 cm or T1-C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4-8 level PF, 4-8 level PF with anterior fusion (AF), 2-3 level PF with AF, 4-8 level AF, and 4-8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility.Eighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF ($76,617), 4-8 level PF ($40,596), 4-8 level PF with AF ($67,098), 4-8 level AF ($31,392), and 4-8 level posterior refusion ($35,371). Average 1-year reimbursement of surgery was $55,097 at 1 year with eight revisions and three deaths accounted for. Cost per quality-adjusted life year (QALY) gained to 1-year follow-up was $646,958 by EQ5D and $477,316 by NDI SF6D. If 1-year benefit is sustained, upper threshold of cost-effectiveness is reached 3-4.5 years after intervention.Medicare 1-year average reimbursement compared with 1-year QALYdescribed $646,958 by EQ5D and $477,316 by NDI SF6D. Cervical deformity surgeries reach accepted cost-effectiveness thresholds when benefit is sustained 3-4.5 years. Longer follow-up is needed for a more definitive cost-analysis, but these data are an important first step in justifying cost-utility ratio for cervical deformity correction.

  View details for DOI 10.1016/j.spinee.2018.01.016

  View details for Web of Science ID 000445024600006

  View details for PubMedID 29499339

• Fractional anisotropy to quantify cervical spondylotic myelopathy severity. Journal of neurosurgical sciences Murphy, R. K., Sun, P., Han, R. H., Griffin, K. J., Wagner, J., Yarbrough, C. K., Wright, N. M., Dorward, I. G., Riew, K. D., Kelly, M. P., Santiago, P., Zebala, L. P., Trinkaus, K., Ray, W. Z., Song, S. K. 2018; 62 (4): 406-412

  Abstract

  A number of clinical tools exist for measuring the severity of cervical spondylotic myelopathy (CSM). Several studies have recently described the use of non-invasive imaging biomarkers to assess severity of disease. These imaging markers may provide an additional tool to measure disease progression and represent a surrogate marker of response to therapy. Correlating these imaging biomarkers with clinical quantitative measures is critical for accurate therapeutic stratification and quantification of axonal injury.Fourteen patients and seven healthy control subjects were enrolled. Patients were classified as mildly (7) or moderately (7) impaired based on Modified Japanese Orthopedic Association Scale. All patients underwent diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI) analyses. In addition to standard neurological examination, all participants underwent 30-m Walking Test, 9-hole Peg Test (9HPT), grip strength, key pinch, and vibration sensation thresholds in the index finger and great toe. Differences in assessment scores between controls, mild and moderate CSM patients were correlated with DTI and DBSI derived fractional anisotropy (FA).Clinically, 30-meter walking times were significantly longer in the moderately impaired group than in the control group. Maximum 9HPT times were significantly longer in both the mildly and moderately impaired groups as compared to normal controls. Scores on great toe vibration sensation thresholds were lower in the mildly impaired and moderately impaired groups as compared to controls. We found no clear evidence for any differences in minimum grip strength, minimum key pinch, or index finger vibration sensation thresholds. There were moderately strong associations between DTI and DBSI FA values and 30-meter walking times and 9HPT.The 30-m Walking Test and 9HPT were both moderately to strongly associated with DTI/DBSI FA values. FA may represent an additional measure to help differentiate and stratify patients with mild or moderate CSM.

  View details for DOI 10.23736/S0390-5616.16.03678-X

  View details for PubMedID 27149369

  View details for PubMedCentralID PMC5097691

• Minimum Detectable Measurement Difference for Health-Related Quality of Life Measures Varies With Age and Disability in Adult Spinal Deformity: Implications for Calculating Minimal Clinically Important Difference. Spine Kelly, M. P., Kim, H. J., Ames, C. P., Burton, D. C., Carreon, L. Y., Polly, D. W., Hostin, R., Jain, A., Gum, J. L., Lafage, V., Schwab, F. J., Shaffrey, C. I., Smith, J. S., Bess, S. 2018; 43 (13): E790-E795

  Abstract

  Retrospective cohort.To investigate the minimum detectable measurement difference (MDMD) in the Scoliosis Research Society-22r (SRS-22r) outcomes instrument in adult spinal deformity (ASD) and to evaluate the effect of baseline data on measurable difference.The minimum clinically important difference (MCID) is the smallest, clinically relevant change observed and has been proposed for the SRS-22r instrument in ASD as 0.4. The MCID must be greater than the MDMD to be useful. The MDMD for the SRS-22r has not been calculated, nor have the effect of patient baseline values on MDMD.A prospective observation cohort was queried for patients treated both operatively and nonoperatively for ASD. Patients with baseline and 1-year, 2-year follow-up SRS-22r data were included in the analysis. The MDMD was calculated using classical test theory and item-response theory methods. Effect size and standardized response means were calculated. The effect of baseline data values was evaluated for MDMD.A total 839 Patients were eligible for cohort inclusion with 428 (51%) eligible for analysis with complete data. MDMD for Pain (0.6) and Self-Image (0.5) were greater than 0.4. MDMD varied with age (highest for the youngest patients) and with disability (highest for SF-36 Physical Component Summary <28.6). MDMD was less than 0.4 for Activity (0.3), Mental Health (0.3), and Total Score (0.2). Gender and mental health did not affect MDMD for the SRS-22r instrument.An MCID of 0.4 for the SRS-22r total score and domain scores may not be an appropriate value as the calculated MDMD is greater than 0.4 for both the Pain and Self-Image subscores. The MDMD for the SRS-22r instrument varied with age and baseline disability, making the assessment of clinically significant change more difficult using this tool. The MCID must be considered in the setting of the MDMD for instruments used to assess outcomes in ASD.3.

  View details for DOI 10.1097/BRS.0000000000002519

  View details for PubMedID 29215503

• Serious Adverse Events Significantly Reduce Patient-Reported Outcomes at 2-Year Follow-up: Nonoperative, Multicenter, Prospective NIH Study of 105 Patients. Spine Pugely, A. J., Kelly, M. P., Baldus, C. R., Gao, Y., Zebala, L., Shaffrey, C., Glassman, S., Boachie-Adjei, O., Parent, S., Lewis, S., Koski, T., Edwards, C., Schwab, F., Bridwell, K. H. 2018; 43 (11): 747-753

  Abstract

  This is an analysis of a prospective 2-year study on nonoperative patients enrolled in the Adult Symptomatic Lumbar Scoliosis (ASLS) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) trial.The purpose was to evaluate the impact of serious adverse events (SAEs) on patient-reported outcomes (PROs) in nonoperative management of ASLS as measured by Scoliosis Research Society-22 (SRS-22), Oswestry Disability Index (ODI), and Short Form-12 (SF-12) at 2-year follow-up.Little is known about PROs in the nonoperative management of ASLS or the prevalence and impact of SAEs on PROs.The ASLS trial dataset was analyzed to identify adult lumbar scoliosis patients electively choosing or randomly assigned to nonoperative treatment with minimum 2-year follow-up. Patient data were collected prospectively from 2010 to 2015 as part of NIAMS R01-AR055176-01A2 "A Multi-Centered Prospective Study of Quality of Life in Adult Scoliosis." SAEs were defined as life-threatening medical events, new significant or permanent disability, new or prolonged hospitalization, or death.One hundred five nonoperative patients were studied to 2-year follow-up. Twenty-seven patients (25.7%) had 42 SAEs; 15 (14.3%) had a SAE during the first year. The SAE group had higher body mass index (29.4 vs. 25.2; P = 0.008) and reported worse SRS-22 Function scores than the non-SAE group at baseline (3.3 vs. 3.6; P = 0.024). At 2-year follow-up, SAE patients experienced less improvement (change) in SRS-22 Self-Image (-0.07 vs. 0.26; P = 0.018) and Mental Health domains (-0.19 vs. 0.25; P = 0.002) than non-SAE patients and had lower SRS-22 Function, Self-Image, Subscore, and SF-12 Mental and Physical component scores (MCS/PCS). Fewer SAE patients reached minimal clinically important difference (MCID) threshold in SRS-22 Mental Health (14.8% vs. 43.6%; P = 0.01).A high percentage (25.7%) of ASLS patients managed nonoperatively experienced SAEs. Those patients who sustained a SAE had less improvement in reported outcomes.2.

  View details for DOI 10.1097/BRS.0000000000002479

  View details for PubMedID 29095407

  View details for PubMedCentralID PMC5930151

• Reoperation and complications after anterior cervical discectomy and fusion and cervical disc arthroplasty: a study of 52,395 cases EUROPEAN SPINE JOURNAL Kelly, M. P., Eliasberg, C. D., Riley, M. S., Ajiboye, R. M., SooHoo, N. F. 2018; 27 (6): 1432-1439

  Abstract

  The aim of this study was to analyze rates of perioperative complications and subsequent cervical surgeries in patients treated for cervical degenerative disc disease with anterior cervical discectomy and fusion (ACDF) and those treated with artificial cervical disc arthroplasty (ACDA) for up to 5-year follow-up.California's Office of Statewide Health Planning and Development discharge database was analyzed for patients aged 18-65 years undergoing single-level ACDF or ACDA between 2003 and 2010. Medical comorbidities were identified with CMS-Condition Categories. Readmissions for short-term complications of the procedure were identified and rates of subsequent cervical surgeries were calculated at 90-day and 1-, 3-, and 5-year follow-up. Multivariate regression modeling was used to identify associations with complications and subsequent cervical surgeries correcting for patient and provider characteristics.A total of 52,395 eligible cases were identified: 50,926 ACDF and 1469 ACDA. Readmission was less common in the ACDA group (OR: 0.69, 95% CI: 0.48-1.0, p = 0.048). Subsequent cervical spine surgery was more common in the ACDF group in the immediate perioperative period (within 90 days of surgery) (ACDF 3.35% vs. ACDA 2.04%, OR: 0.63, 95% CI: 0.44-0.92, p = 0.015). At 1-, 3-, and 5-year postoperatively, rates of subsequent cervical surgeries were similar between the two cohorts.We found no protective benefit for ACDA versus ACDF for single-level disease at up to 5-year follow-up in the largest cohort of patients examined to date. Early complications were rare in both cohorts stressing the value of large cohort studies to study risk factors for rare events. These slides can be retrieved under Electronic Supplementary Material.

  View details for DOI 10.1007/s00586-018-5570-8

  View details for Web of Science ID 000433331800031

  View details for PubMedID 29605899

  View details for PubMedCentralID PMC6488512

• Clinical and Radiographic Outcomes After Posterior Vertebral Column Resection for Severe Spinal Deformity with Five-Year Follow-up JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Riley, M. S., Lenke, L. G., Chapman, T. M., Sides, B. A., Blanke, K. M., Kelly, M. P. 2018; 100 (5): 396-405

  Abstract

  Short-term studies have shown improved outcomes and alignment after posterior vertebral column resection for severe spinal deformity. Our goal was to report long-term changes in radiographic and health-related quality-of-life measures in a consecutive series of pediatric and adult patients undergoing posterior vertebral column resection with a minimum follow-up of 5 years.We reviewed all patients undergoing posterior vertebral column resection by a single surgeon prior to January 1, 2010, at a single institution. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22/24 instrument. Radiographic and health-related quality-of-life measures changes were evaluated at a minimum follow-up of 5 years.One hundred and nine patients underwent posterior vertebral column resection prior to January 2010, and 54 patients (49.5%) were available for analysis: 31 (57.4%) were pediatric patients, and 23 (42.6%) were adult patients. The mean age (and standard deviation) was 12.5 ± 3 years for the pediatric cohort and 39.3 ± 20 years for the adult cohort. Improvements in the mean major Cobb angle at a minimum follow-up of 5 years were seen: 61.6% correction for the pediatric cohort and 53.9% correction for the adult cohort. The rates of proximal junctional kyphosis, defined as proximal junctional kyphosis of >10°, were 16.1% for the pediatric cohort and 34.8% for the adult cohort, but none underwent a revision surgical procedure for symptomatic proximal junctional kyphosis. Of the 54 patients, 30 (55.6%) sustained complications, 5 (9.3%) experienced postoperative neurological deficits, and 7 (13.0%) required a revision by 5 years postoperatively. Significant improvements were observed in the SRS-Self Image with regard to the pediatric cohort at 0.9 (p = 0.017) and the adult cohort at 1.3 (p = 0.002) and in the SRS-Satisfaction with regard to the pediatric cohort at 1.8 (p = 0.008) and the adult cohort at 1.3 (p = 0.005).Posterior vertebral column resection offers substantial, sustained improvements in global radiographic alignment and patient outcome scores at 5 years. The major radiographic deformity was reduced by 61.6% in the pediatric cohort and by 53.9% in the adult cohort. Despite the high rate of complications, patients experienced significant improvement in the SRS-Self Image and SRS-Satisfaction domains.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.17.00597

  View details for Web of Science ID 000429160300014

  View details for PubMedID 29509617

• Operative Management of Adult Spinal Deformity Results in Significant Increases in QALYs Gained Compared to Nonoperative Management: Analysis of 479 Patients With Minimum 2-Year Follow-Up. Spine Scheer, J. K., Hostin, R., Robinson, C., Schwab, F., Lafage, V., Burton, D. C., Hart, R. A., Kelly, M. P., Keefe, M., Polly, D., Bess, S., Shaffrey, C. I., Smith, J. S., Ames, C. P. 2018; 43 (5): 339-347

  Abstract

  Retrospective review of prospective multicenter adult spinal deformity (ASD) database.To compare the quality-adjusted life years (QALYs) between operative and nonoperative treatments for ASD patients.Operative management of ASD repeatedly demonstrates improvements in HRQOL over nonoperative treatment. However, little is reported regarding QALY improvements after surgical correction of ASD.Inclusion criteria: ≥18 years, ASD. Health utility values were calculated from SF6D scores and used to calculate QALYs at minimum 2 years from the baseline utility value as well as at 1, 2, and 3 years for the available patients. A 1:1 propensity score matching using six baseline variables was conducted to account for the nonrandom distribution of operative and nonoperative treatments.Four hundred seventy-nine patients were included (OP:258, 70.7%, NONOP:221, 47.1%). One hundred fifty-one (OP:90, NONOP:61) had complete 1, 2, and 3 year data available for QALY trending. Unmatched results are not listed in the abstract. Mean baseline utility scores were statistically similar between the matched groups (OP: 0.609 ± 0.093, NONOP: 0.600 ± 0.091, P = 0.6401) and at 2 year min postop mean OP QALY was greater than NONOP (1.377 ± 0.345 vs. 1.256 ± 0.286, respectively, P < 0.01). For the subanalysis cohort, mean OP QALYs at 1, 2, and 3 years postoperative were all significantly greater than NONOP, P < 0.03 for all (1 yr: 0.651 ± 0.089 vs. 0.61 ± 0.079, 2 yr: 1.29 ± 0.157 vs. 1.189 ± 0.141, and 3 yr: 1.903 ± 0.235 vs. 1.749 ± 0.198, respectively). Matched OP had a larger QALYs gained (from baseline) at 2 year minimum postoperative (0.112 ± 0.243 vs. 0.008 ± 0.195, P < 0.01). For subanalysis of patients with complete 1 to 3 years data, OP had a significantly larger QALYs gained at 1, 2, and 3 years compared with NONOP: 1 year (0.073 ± 0.121 vs. 0.029 ± 0.082, P = 0.0447), 2 years (0.167 ± 0.232 vs. 0.036 ± 0.173, P = 0.0030), and 3years (0.238 ± 0.379 vs. 0.059 ± 0.258, P < 0.01).The operative treatment of adult spinal deformity results in significantly greater mean QALYs and QALYs gained at minimum 2 years postop as well as at the 1-, 2-, and 3-year time points compared with nonoperative management.3.

  View details for DOI 10.1097/BRS.0000000000001626

  View details for PubMedID 27253084

• Key Role of Preoperative Recumbent Films in the Treatment of Severe Sagittal Malalignment. Spine deformity Karikari, I. O., Lenke, L. G., Bridwell, K. H., Tauchi, R., Kelly, M. P., Sugrue, P. A., Bumpass, D. B., Elsamadicy, A. A., Adogwa, O., Lalezari, R., Koester, L., Blanke, K., Gum, J. 2018; 6 (5): 568-575

  Abstract

  Retrospective cohort study.To determine if severe sagittal malalignment (SM) patients without fixed deformities require a three-column osteotomy (3CO) to achieve favorable clinical and radiographic outcomes.3CO performed for severe SM has significantly increased in the last 15 years. Not all severe SM patients require a 3CO.Severe SM patients (sagittal vertical axis [SVA] >10 cm) who underwent deformity correction between 2002 and 2011. Patients with <33% change in their lumbar lordosis (LL) on a preoperative supine radiograph were classified as stiff deformities, whereas those with ≥33% change were categorized as flexible deformities. The clinical/radiographic outcomes were assessed at minimum two years postoperatively.Seventy patients met the inclusion criteria, 35 patients with flexible and 35 with stiff deformities. Eighteen flexible-deformity patients underwent a 3CO versus 22 stiff-deformity patients. The remaining patients in each group underwent spinal realignment without a 3CO. The flexible-deformity patients not undergoing a 3CO had overall improvement in all sagittal radiographic parameters. Preoperative LL (22°), LL-pelvic incidence (PI) mismatch (43), SVA (17 cm), and pelvic tilt (PT, 34°) improved to 46°, 18, 6 cm, and 26°, respectively, p < .05. Flexible-deformity patients who underwent a 3CO also had overall improvement in all radiographic parameters. Preoperative LL (8.5°), LL-PI mismatch (47), SVA (19 cm), and PT (37°) improved to 39°, 15, 7 cm, and 24°, respectively (p < .05). Stiff-deformity patients who underwent a 3CO had statistically significant improvement in all radiographic parameters. However, stiff-deformity patients who did not undergo a 3CO had suboptimal improvement in all radiographic parameters, except for SVA (14 cm-9 cm, p < .05). Flexible patients who did not undergo a 3CO had statistical improvement in the SRS domains of function and self-mage as well as in their ODI scores (p < .05).Severe SM that is flexible can be corrected without a 3CO without compromising clinical and radiographic outcomes.Level III.

  View details for DOI 10.1016/j.jspd.2018.02.009

  View details for PubMedID 30122393

• Health-related quality of life outcomes in complex adult spinal deformity surgery. Journal of neurosurgery. Spine Riley, M. S., Bridwell, K. H., Lenke, L. G., Dalton, J., Kelly, M. P. 2018; 28 (2): 194-200

  Abstract

  OBJECTIVE Significant health-related quality of life (HRQOL) benefits have been observed for patients undergoing primary and revision adult spinal deformity (ASD) surgery. The purpose of this study was to report changes in HRQOL measures in a consecutive series of patients undergoing complex spinal reconstructive surgery, using Scoli-RISK-1 (SR-1) inclusion criteria. METHODS This was a single-center, retrospective cohort study. The SR-1 inclusion criteria were used to define patients with complex ASD treated between June 1, 2009, and June 1, 2011. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22r instrument. The HRQOL changes were evaluated at a minimum 2-year follow-up. Standardized forms were used to collect surgery-related complications data for all patients. Complications were defined as minor, transient major, or permanent major. Patients who achieved a minimum 2-year follow-up were included in the analysis. RESULTS Eighty-four patients meeting SR-1 criteria were identified. Baseline demographic and surgical data were available for 74/84 (88%) patients. Forty-seven of 74 (64%) patients met the additional HRQOL criteria with a minimum 2-year follow-up (mean follow-up 3.4 years, range 2-6.5 years). Twenty-one percent of patients underwent posterior fusion only, 40% of patients had a posterior column osteotomy, and 38% had a 3-column osteotomy. Seventy-five percent of patients underwent a revision procedure. Significant improvements were observed in all SRS-22r domains: Pain: +0.8 (p < 0.001); Self-Image: +1.4 (p < 0.001); Function: +0.46 (p < 0.001); Satisfaction: +1.6 (p < 0.001); and Mental Health: +0.28 (p = 0.04). With the exception of Mental Health, more than 50% of patients achieved a minimum clinically important difference (MCID) in SRS-22r domain scores (Mental Health: 20/47, 42.6%). A total of 65 complications occurred in 31 patients. This includes 29.8% (14/47) of patients who suffered a major complication and 17% (8/47) who suffered a postoperative neurological deficit, most commonly at the root level (10.6%, 5/47). Of the 8 patients who suffered a neurological deficit, 1 (13%) was able to achieve MCID in the SRS Function domain. CONCLUSIONS The majority of patients experienced clinically relevant improvement in SRS-22r HRQOL scores after complex ASD surgery. The greatest improvements were seen in the SRS Pain and SRS Self-Image domains. Although 30% of patients suffered a major or permanent complication, benefits from surgery were still attained. Patients sustaining a neurological deficit or major complication were unlikely to achieve HRQOL improvements meeting or exceeding MCID for the SRS Function domain.

  View details for DOI 10.3171/2017.6.SPINE17357

  View details for PubMedID 29171797

• Dural Tears in Adult Deformity Surgery: Incidence, Risk Factors, and Outcomes. Global spine journal Iyer, S., Klineberg, E. O., Zebala, L. P., Kelly, M. P., Hart, R. A., Gupta, M. C., Hamilton, D. K., Mundis, G. M., Sciubba, D., Ames, C. P., Smith, J. S., Lafage, V., Burton, D., Kim, H. J. 2018; 8 (1): 25-31

  Abstract

  Retrospective cohort study.Describe the rate of dural tears (DTs) in adult spinal deformity (ASD) surgery. Describe the risk factors for DT and the impact of this complication on clinical outcomes.Patients with ASD undergoing surgery between 2008 and 2014 were separated into DT and non-DT cohorts; demographics, operative details, radiographic, and clinical outcomes were compared. Statistical analysis included t tests or χ2 tests as appropriate and a multivariate analysis.A total of 564 patients were identified. The rate of DT was 10.8% (n = 61). Patients with DT were older (61.1 vs 56.5 years, P = .005) and were more likely to have had prior spine surgery (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.2-3.3, P = .007). DT patients had higher pelvic tilt, lower lumbar lordosis, and greater pelvic-incidence lumbar lordosis mismatch than non-DT patients (P < .05). DT patients had longer operative times (424 vs 375 minutes, P = .008), were more likely to undergo interbody fusions (OR = 2.0, 95% CI = 1.1-3.6, P = .021), osteotomies (OR = 2.2, 95% CI = 1.1-4.0, P = .012), and decompressions (OR = 2.3, 95% CI = 1.3-4.3, P = .003). In our multivariate analysis, only decompressions were associated with an increased risk of DT (OR = 3.2, 95% CI = 1.4-7.6, P = .006). There were no significant differences in patient outcomes at 2 years.The rate of DT was 10.8% in an ASD cohort. This is similar to rates of DT reported following surgery for degenerative pathology. A history of prior spine surgery, decompression, interbody fusion, and osteotomies are all associated with an increased risk of DT, but decompression is the only independent risk factor for DT.

  View details for DOI 10.1177/2192568217717973

  View details for PubMedID 29456912

  View details for PubMedCentralID PMC5810895

• Surgical Indications in Neuromuscular Scoliosis NEUROMUSCULAR SPINE DEFORMITY Lawing, C. R., Kelly, M. P., Sponseller, P. D., Samdani, A., Newton, P., Sponseller, P., Shufflebarger, H., Betz, R. 2018: 11-19

  View details for Web of Science ID 000618842800005

• Adult Spinal Deformity Kelly , M., Youssef , J. AAOS Comprehensive Orthopaedic Review, 3rd Edition. 2018
• Preoperative Evaluation and Optimization NEUROMUSCULAR SPINE DEFORMITY Kelly, M. P., Luhmann, S. J., Samdani, A., Newton, P., Sponseller, P., Shufflebarger, H., Betz, R. 2018: 2-6

  View details for Web of Science ID 000618842800003

• Posterior-Only Vertebral Column Resection for Fused Spondyloptosis. Spine deformity Gum, J. L., Lenke, L. G., Mohapatra, A., Sun, S. Q., Kelly, M. P. 2018; 6 (1): 84-95

  Abstract

  Retrospective review.To describe 3 cases of a posterior-only vertebral column resection (pVCR) for the treatment of spondyloptosis in the setting of prior spinal fusions.Lumbosacral spondyloptosis is a rare spinal deformity with a number of surgical options, none of which demonstrate clear superiority. The use of an L5 vertebral column resection, via combined anterior and posterior approaches, to restore lumbosacral alignment has been described though is accompanied by high rates of neurological deficit.Review of 3 cases of spondyloptosis with prior spinal fusions in which a staged pVCR was used for deformity reconstruction.Three females, ages 39, 54, and 28, developed spondyloptosis with progressive lumbosacral kyphosis and sagittal malalignment after prior in-situ posterolateral spinal fusions. All were treated with staged pVCRs. At ultimate follow-up, imaging revealed improvement in sagittal balance of 6.1 cm (56%) in the 39-year-old and 12 cm (67%) in the 54-year-old, 21.1 cm (92%) in the 28-year-old. All patients had improvement in outcome scores with perfect satisfaction scores despite the 54-year-old having a persistent right foot drop.Posterior-only VCR for spondyloptosis is a technically demanding surgical option offering significant radiographic and clinical improvement, but carries a risk for L5 nerve root deficit as in any spondyloptosis treatment.

  View details for DOI 10.1016/j.jspd.2017.06.002

  View details for PubMedID 29287823

• SRS-22R Minimum Clinically Important Difference and Substantial Clinical Benefit After Adult Lumbar Scoliosis Surgery. Spine deformity Carreon, L. Y., Kelly, M. P., Crawford, C. H., Baldus, C. R., Glassman, S. D., Shaffrey, C. I., Bridwell, K. H. 2018; 6 (1): 79-83

  Abstract

  Longitudinal cohort.To determine if the minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds for the Scoliosis Research Society-22R (SRS22R) domains in patients with degenerative lumbar scoliosis are similar to those in patients with adult spinal deformity (ASD) with fusions extending into the thoracic spine.The MCID and SCB thresholds for the SRS22R domains in patients with ASD and adolescent idiopathic scoliosis have been reported.Patients enrolled in the NIH-sponsored Adult Symptomatic Lumbar Scoliosis (ASLS) trial who underwent surgery and completed the SRS22R preoperative and the SRS30 one-year postoperative were identified. One-year postoperative answers to the last eight questions of the SRS30 were used as anchors to determine the MCID and SCB for the Pain, Appearance, and Activity domains, and the Subscore and Total score using receiver operating characteristic (ROC) curve analysis.The sample population consisted of 147 patients. A total of 132 (89%) were females with a mean age of 59.4 years. There was a statistically significant improvement in all SRS22R scores from preoperative to one-year postoperative. There was also a statistically significant difference in domain scores among the different responses to the anchors. According to the ROC analysis, MCID was 1.17 for Appearance, 0.40 for Activity, 0.60 for Pain, 0.53 for Subscore, and 0.77 for Total; and SCB was 1.67 for Appearance, 0.60 for Activity, 0.62 for Subscore, and 1.11 for Total score. These are similar to previous reports of MCID and SCB thresholds for ASD patients who underwent fusion to the thoracic spine.The MCID and SCB thresholds for the SRS22R domains in patients with adult symptomatic lumbar scoliosis are very similar to the threshold values previously reported for adult deformity patients.Level II.

  View details for DOI 10.1016/j.jspd.2017.05.006

  View details for PubMedID 29287822

  View details for PubMedCentralID PMC5751965

• Adult Spinal Deformity Knowledge in Orthopedic Spine Surgeons: Impact of Fellowship Training, Experience, and Practice Characteristics. Spine deformity Grabel, Z. J., Hart, R. A., Clark, A. J., Park, S. H., Shaffrey, C. I., Scheer, J. K., Smith, J. S., Kelly, M. P., DePasse, J. M., Gupta, M. C., Ames, C. P., Daniels, A. H. 2018; 6 (1): 60-66

  Abstract

  Survey study.The purpose of this paper was to assess the level of adult spine deformity (ASD) knowledge among orthopedic spine surgeons and identify areas for improvement in spine surgery training.ASD is increasingly encountered in spine surgery practice. While ASD knowledge among neurosurgeons has been evaluated, ASD knowledge among orthopedic spine surgeons has not previously been reported.A survey of orthopedic spine surgeon members of North American Spine Society (NASS) was conducted to assess level of spine surgery training, practice experience, and spinal deformity knowledge base. The survey used was previously completed by a group of neurologic surgeons with published results. The survey used 11 questions developed and agreed upon by experienced spinal deformity surgeons.Complete responses were received from 413 orthopedic spine surgeons. The overall correct-answer rate was 69.0%. Surgeons in practice for less than 10 years had a higher correct-answer rate compared to those who have practiced for 10 years or more (74% vs. 67%; p = .000003). Surgeons with 75% or more of their practice dedicated to spine had a higher overall correct rate compared to surgeons whose practice is less than 75% spine (71% vs. 63%; p = .000029). Completion of spine fellowship was associated with a higher overall correct-answer rate compared to respondents who did not complete a spine fellowship (71% vs. 59%; p < .00001).Completion of spine fellowship and having a dedicated spine surgery practice were significantly associated with improved performance on this ASD knowledge survey. Unlike neurosurgeons, orthopedic spine surgeons who have practiced for less than 10 years performed better than those who have practiced for more than 10 years. Ongoing emphasis on spine deformity education should be emphasized to improve adult spinal deformity knowledge base.

  View details for DOI 10.1016/j.jspd.2017.06.003

  View details for PubMedID 29287819

• Incidence of Cancer in Spinal Deformity Patients Receiving High-Dose (≥40 mg) Bone Morphogenetic Protein (rhBMP-2). Spine Baldus, C., Kelly, M. P., Yanik, E. L., Drake, B. F., Ahmad, A., Mesfin, A., Bridwell, K. H. 2017; 42 (23): 1785-1791

  Abstract

  Level III, Retrospective observational study.To determine if there is an increased risk of developing cancer after exposure to high-dose recombinant human bone morphogenetic protein-2 (rhBMP-2) and if risk is dose and/or exposure-dependent.Concerns have been raised regarding a relationship between rhBMP-2 and cancer.A total of 642 adult deformity patients from a single institution receiving a cumulative rhBMP-2 dose ≥40 mg from July, 2002 to July, 2009 were identified. Patients with a history of surveillance, epidemiology, and end result (SEER) cancer before rhBMP-2 exposure were excluded. To determine the occurrence of a cancer event, questionnaires were mailed and telephone follow up attempted for nonresponders. Only cancers tracked by the National Cancer Institute (NCI) SEER registry were included. Observed cancer counts were compared to expected cancer counts based on general population incidence rates within 5-year age strata. Cumulative incidence competing risk (CICR) modeling was used to evaluate the association between rhBMP-2 exposure and cancer controlling for potential confounding variables.Forty-nine patients were lost-to-follow up, leaving 593 patients (92.4%; 138 males/455 females) available for analysis. Mean age was 52.8 years at the time of first exposure. Mean cumulative rhBMP-2 dose was 113.5 mg with 85% having one exposure (range: 1-8). Mean follow-up [date of exposure to date of death (regardless of cause) or returned completed questionnaire] was 5.6 ± 1.9 years; median follow up was 5.4 years. A total of 342 patients have greater than 5-year follow up. Minimum follow up was 2.0 years or until occurrence of a SEER cancer. Our total 8-year cumulative incidence of new SEER cancer accounting for the competing risk of death was 7.4% for 30 cancers in 593 patients. Fewer cancers were observed than expected based on general population rates, though the difference was not statistically significant (expected = 34; standardized incidence ratio = 0.88, 95% confidence interval, CI = 0.60-1.26). CICR found neither cumulative rhBMP-2 dose (hazard ratio, HR = 0.995, 95% CI 0.988-1.003; P = 0.249) nor number of exposures (HR = 0.776, 95% CI 0.359-1.677; P = 0.519) increased the risk of developing a postexposure cancer after controlling for known cancer risk factors.The incidence of a SEER cancer after rhBMP-2 exposure was similar to incidence reported by the NCI. There were no significant rhBMP-2 dose or multi-exposure related risks of developing a life-threatening cancer.3.

  View details for DOI 10.1097/BRS.0000000000002232

  View details for PubMedID 28498289

• Despite worse baseline status depressed patients achieved outcomes similar to those in nondepressed patients after surgery for cervical deformity. Neurosurgical focus Poorman, G. W., Passias, P. G., Horn, S. R., Frangella, N. J., Daniels, A. H., Hamilton, D. K., Kim, H., Sciubba, D., Diebo, B. G., Bortz, C. A., Segreto, F. A., Kelly, M. P., Smith, J. S., Neuman, B. J., Shaffrey, C. I., LaFage, V., LaFage, R., Ames, C. P., Hart, R., Mundis, G. M., Eastlack, R. 2017; 43 (6): E10

  Abstract

  OBJECTIVE Depression and anxiety have been demonstrated to have negative impacts on outcomes after spine surgery. In patients with cervical deformity (CD), the psychological and physiological burdens of the disease may overlap without clear boundaries. While surgery has a proven record of bringing about significant pain relief and decreased disability, the impact of depression and anxiety on recovery from cervical deformity corrective surgery has not been previously reported on in the literature. The purpose of the present study was to determine the effect of depression and anxiety on patients' recovery from and improvement after CD surgery. METHODS The authors conducted a retrospective review of a prospective, multicenter CD database. Patients with a history of clinical depression, in addition to those with current self-reported anxiety or depression, were defined as depressed (D group). The D group was compared with nondepressed patients (ND group) with a similar baseline deformity determined by propensity score matching of the cervical sagittal vertical axis (cSVA). Baseline demographic, comorbidity, clinical, and radiographic data were compared among patients using t-tests. Improvement of symptoms was recorded at 3 months, 6 months, and 1 year postoperatively. All health-related quality of life (HRQOL) scores collected at these follow-up time points were compared using t-tests. RESULTS Sixty-six patients were matched for baseline radiographic parameters: 33 with a history of depression and/or current depression, and 33 without. Depressed patients had similar age, sex, race, and radiographic alignment: cSVA, T-1 slope minus C2-7 lordosis, SVA, and T-1 pelvic angle (p > 0.05). Compared with nondepressed individuals, depressed patients had a higher incidence of osteoporosis (21.2% vs 3.2%, p = 0.028), rheumatoid arthritis (18.2% vs 3.2%, p = 0.012), and connective tissue disorders (18.2% vs 3.2%, p = 0.012). At baseline, the D group had greater neck pain (7.9 of 10 vs 6.6 on a Numeric Rating Scale [NRS], p = 0.015), lower mean EQ-5D scores (68.9 vs 74.7, p < 0.001), but similar Neck Disability Index (NDI) scores (57.5 vs 49.9, p = 0.063) and myelopathy scores (13.4 vs 13.9, p = 0.546). Surgeries performed in either group were similar in terms of number of levels fused, osteotomies performed, and correction achieved (baseline to 3-month measurements) (p < 0.05). At 3 months, EQ-5D scores remained lower in the D group (74.0 vs 78.2, p = 0.044), and NDI scores were similar (48.5 vs 39.0, p = 0.053). However, neck pain improved in the D group (NRS score of 5.0 vs 4.3, p = 0.331), and modified Japanese Orthopaedic Association (mJOA) scores remained similar (14.2 vs 15.0, p = 0.211). At 6 months and 1 year, all HRQOL scores were similar between the 2 cohorts. One-year measurements were as follows: NDI 39.7 vs 40.7 (p = 0.878), NRS neck pain score of 4.1 vs 5.0 (p = 0.326), EQ-5D score of 77.1 vs 78.2 (p = 0.646), and mJOA score of 14.0 vs 14.2 (p = 0.835). Anxiety/depression levels reported on the EQ-5D scale were significantly higher in the depressed cohort at baseline, 3 months, and 6 months (all p < 0.05), but were similar between groups at 1 year postoperatively (1.72 vs 1.53, p = 0.416). CONCLUSIONS Clinical depression was observed in many of the study patients with CD. After matching for baseline deformity, depression symptomology resulted in worse baseline EQ-5D and pain scores. Despite these baseline differences, both cohorts achieved similar results in all HRQOL assessments 6 months and 1 year postoperatively, demonstrating no clinical impact of depression on recovery up until 1 year after CD surgery. Thus, a history of depression does not appear to have an impact on recovery from CD surgery.

  View details for DOI 10.3171/2017.8.FOCUS17486

  View details for PubMedID 29191101

• Lumbar computed tomography scans are not appropriate surrogates for bone mineral density scans in primary adult spinal deformity. Neurosurgical focus Kohan, E. M., Nemani, V. M., Hershman, S., Kang, D. G., Kelly, M. P. 2017; 43 (6): E4

  Abstract

  OBJECTIVE The authors examined the correlation between lumbar spine CT Hounsfield unit (HU) measurements and bone mineral density measurements in an adult spinal deformity (ASD) population. METHODS Patients with ASD were identified in the records of a single institution. Lumbar CT scans were reviewed, and the mean HU measurements from L1-4 were recorded. Bone mineral density (BMD) was assessed using femoral neck and lumbar spine dual-energy x-ray absorptiometry (DEXA). The number of patients who met criteria for osteoporosis was determined for each imaging modality. RESULTS Forty-eight patients underwent both preoperative DEXA and CT scanning. Forty-three patients were female and 5 were male. Forty-seven patients were Caucasian and one was African American. The mean age of the patients was 62.1 years. Femoral neck DEXA was more likely to identify osteopenia (n = 26) than lumbar spine DEXA (n = 8) or lumbar CT HU measurements (n = 6) (p < 0.001). There was a low-moderate correlation between lumbar spine CT and lumbar spine DEXA (r = 0.463, p < 0.001), and there was poor correlation between lumbar spine CT and femoral neck DEXA (r = 0.303, p = 0.036). CONCLUSIONS Despite the opportunistic utility of lumbar spine CT HU measurements in identifying osteoporosis in patients undergoing single-level fusion, these measurements were not useful in this cohort of ASD patients. The correlation between femoral neck DEXA and HU measurements was poor. DEXA assessment of BMD in ASD patients is essential to optimize the care of these complicated cases.

  View details for DOI 10.3171/2017.9.FOCUS17476

  View details for PubMedID 29191096

• Male sex may not be associated with worse outcomes in primary all-posterior adult spinal deformity surgery: a multicenter analysis. Neurosurgical focus Bumpass, D. B., Lenke, L. G., Gum, J. L., Shaffrey, C. I., Smith, J. S., Ames, C. P., Bess, S., Neuman, B. J., Klineberg, E., Mundis, G. M., Schwab, F., Lafage, V., Kim, H. J., Burton, D. C., Kebaish, K. M., Hostin, R., Lafage, R., Kelly, M. P. 2017; 43 (6): E9

  Abstract

  OBJECTIVE Adolescent spine deformity studies have shown that male patients require longer surgery and have greater estimated blood loss (EBL) and complications compared with female patients. No studies exist to support this relationship in adult spinal deformity (ASD). The purpose of this study was to investigate associations between sex and complications, deformity correction, and health-related quality of life (HRQOL) in patients with ASD. It was hypothesized that male ASD patients would have greater EBL, longer surgery, and more complications than female ASD patients. METHODS A multicenter ASD cohort was retrospectively queried for patients who underwent primary posterior-only instrumented fusions with a minimum of 5 levels fused. The minimum follow-up was 2 years. Primary outcomes were EBL, operative time, intra-, peri-, and postoperative complications, radiographic correction, and HRQOL outcomes (Oswestry Disability Index, SF-36, and Scoliosis Research Society-22r Questionnaire). Poisson multivariate regression was used to control for age, comorbidities, and levels fused. RESULTS Ninety male and 319 female patients met the inclusion criteria. Male patients had significantly greater mean EBL (2373 ml vs 1829 ml, p = 0.01). The mean operative time, transfusion requirements, and final radiographic measurements did not differ between sexes. Similarly, changes in HRQOL showed no significant differences. Finally, there were no sex differences in the incidence of complications (total, major, or minor) at any time point after controlling for age, body mass index, comorbidities, and levels fused. CONCLUSIONS Despite higher EBL, male ASD patients did not experience more complications or require less deformity correction at the 2-year follow-up. HRQOL scores similarly showed no sex differences. These findings differ from adolescent deformity studies, and surgeons can counsel patients that sex is unlikely to influence the outcomes and complication rates of primary all-posterior ASD surgery.

  View details for DOI 10.3171/2017.9.FOCUS17475

  View details for PubMedID 29191095

• Incidence of perioperative medical complications and mortality among elderly patients undergoing surgery for spinal deformity: analysis of 3519 patients. Journal of neurosurgery. Spine Jain, A., Hassanzadeh, H., Puvanesarajah, V., Klineberg, E. O., Sciubba, D. M., Kelly, M. P., Hamilton, D. K., Lafage, V., Buckland, A. J., Passias, P. G., Protopsaltis, T. S., Lafage, R., Smith, J. S., Shaffrey, C. I., Kebaish, K. M. 2017; 27 (5): 534-539

  Abstract

  OBJECTIVE Using 2 complication-reporting methods, the authors investigated the incidence of major medical complications and mortality in elderly patients after surgery for adult spinal deformity (ASD) during a 2-year follow-up period. METHODS The authors queried a multicenter, prospective, surgeon-maintained database (SMD) to identify patients 65 years or older who underwent surgical correction of ASD from 2008 through 2014 and had a minimum 2 years of follow-up (n = 153). They also queried a Centers for Medicare & Medicaid Services claims database (MCD) for patients 65 years or older who underwent fusion of 8 or more vertebral levels from 2005 through 2012 (n = 3366). They calculated cumulative rates of the following complications during the first 6 weeks after surgery: cerebrovascular accident, congestive heart failure, deep venous thrombosis, myocardial infarction, pneumonia, and pulmonary embolism. Significance was set at p < 0.05. RESULTS During the perioperative period, rates of major medical complications were 5.9% for pneumonia, 4.1% for deep venous thrombosis, 3.2% for pulmonary embolism, 2.1% for cerebrovascular accident, 1.8% for myocardial infarction, and 1.0% for congestive heart failure. Mortality rates were 0.9% at 6 weeks and 1.8% at 2 years. When comparing the SMD with the MCD, there were no significant differences in the perioperative rates of major medical complications except pneumonia. Furthermore, there were no significant intergroup differences in the mortality rates at 6 weeks or 2 years. The SMD provided greater detail with respect to deformity characteristics and surgical variables than the MCD. CONCLUSIONS The incidence of most major medical complications in the elderly after surgery for ASD was similar between the SMD and the MCD and ranged from 1% for congestive heart failure to 5.9% for pneumonia. These complications data can be valuable for preoperative patient counseling and informed consent.

  View details for DOI 10.3171/2017.3.SPINE161011

  View details for PubMedID 28820363

• Importance of patient-reported individualized goals when assessing outcomes for adult spinal deformity (ASD): initial experience with a Patient Generated Index (PGI). The spine journal : official journal of the North American Spine Society Scheer, J. K., Keefe, M., Lafage, V., Kelly, M. P., Bess, S., Burton, D. C., Hart, R. A., Jain, A., Lonner, B. S., Protopsaltis, T. S., Hostin, R., Shaffrey, C. I., Smith, J. S., Schwab, F., Ames, C. P. 2017; 17 (10): 1397-1405

  Abstract

  Current metrics to assess patients' health-related quality of life (HRQOL) may not reflect a true change in the patients' specific perception of what is most important to them.This study aimed to describe the initial experience of a Patient Generated Index (PGI) in which patients create their own outcome domains.This is a single-center prospective study.Patients with adult spinal deformity (ASD) comprise the study sample.Oswestry Disability Index (ODI), Short Form-36 (SF-36 Physical Component Score [PCS] and Mental Component Score [MCS]), Scoliosis Research Society-22r (SRS-22r), and PGI.Oswestry Disability Index, SF-36, SRS-22r, and PGI were administered preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 and 2 years. PGI correlations with ODI, SF-36, SRS total score, free-text frequency analysis of PGI exact response with text in ODI and SRS-22r questionnaires, and the responsiveness (effect size [ES]) of the HRQOL metrics were analyzed. No funding was used for this study and there are no conflicts of interest.A total of 59 patients with 209 clinical encounters produced 370 PGI written response topics that included affect or emotions, relationships, activities of daily life, personal care, work, and hobbies. Mean preoperative PGI score was 18.6±13.5 (0-71.7 out of 100 [best]), and mean scores significantly improved at every postoperative time point (p<.05). Preoperative PGI scores significantly correlated with preoperative ODI (r=-0.28, p=.03), MCS (r=0.48, p<.01), and SRS total (r=0.57, p<.01). Postoperative PGI scores correlated with all HRQOL measures (p<.0001): ODI (r=-0.65), PCS (r=0.50), MCS (r=0.55), and SRS total (r=0.63). PGI responses exactly matched ODI and SRS-22r text at 47.8% and 35.4%, respectively, and at 63.2% and 58.9%, respectively, for categories. Patient Generated Index ES at a minimum of 1-year follow-up was -2.39, indicating substantial responsiveness (|ES|>0.8). Effect sizes for ODI, SRS-22r total, SF-36 PCS, and SF-36 MCS were 2.16, -2.06, -2.05, and -0.80, respectively.The PGI is easy to administer and offers additional information about the patients' perspective not captured in standard HRQOL metrics. Patient Generated Index scores correlated with all of the standard HRQOL scores and were more responsive than ODI, SF-36, and SRS-22r, suggesting that the PGI may be a step closer to one HRQOL measure that better encompasses concerns and goals of the individual patients.

  View details for DOI 10.1016/j.spinee.2017.04.013

  View details for PubMedID 28414170

• Complication rates associated with 3-column osteotomy in 82 adult spinal deformity patients: retrospective review of a prospectively collected multicenter consecutive series with 2-year follow-up. Journal of neurosurgery. Spine Smith, J. S., Shaffrey, C. I., Klineberg, E., Lafage, V., Schwab, F., Lafage, R., Kim, H. J., Hostin, R., Mundis, G. M., Gupta, M., Liabaud, B., Scheer, J. K., Diebo, B. G., Protopsaltis, T. S., Kelly, M. P., Deviren, V., Hart, R., Burton, D., Bess, S., Ames, C. P. 2017; 27 (4): 444-457

  Abstract

  OBJECTIVE Although 3-column osteotomy (3CO) can provide powerful alignment correction in adult spinal deformity (ASD), these procedures are complex and associated with high complication rates. The authors' objective was to assess complications associated with ASD surgery that included 3CO based on a prospectively collected multicenter database. METHODS This study is a retrospective review of a prospectively collected multicenter consecutive case registry. ASD patients treated with 3CO and eligible for 2-year follow-up were identified from a prospectively collected multicenter ASD database. Early (≤ 6 weeks after surgery) and delayed (> 6 weeks after surgery) complications were collected using standardized forms and on-site coordinators. RESULTS Of 106 ASD patients treated with 3CO, 82 (77%; 68 treated with pedicle subtraction osteotomy [PSO] and 14 treated with vertebral column resection [VCR]) had 2-year follow-up (76% women, mean age 60.7 years, previous spine fusion in 80%). The mean number of posterior fusion levels was 12.9, and 17% also had an anterior fusion. A total of 76 early (44 minor, 32 major) and 66 delayed (13 minor, 53 major) complications were reported, with 41 patients (50.0%) and 45 patients (54.9%) affected, respectively. Overall, 64 patients (78.0%) had at least 1 complication, and 50 (61.0%) had at least 1 major complication. The most common complications were rod breakage (31.7%), dural tear (20.7%), radiculopathy (9.8%), motor deficit (9.8%), proximal junctional kyphosis (PJK, 9.8%), pleural effusion (8.5%), and deep wound infection (7.3%). Compared with patients who did not experience early or delayed complications, those who had these complications did not differ significantly with regard to age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, smoking status, history of previous spine surgery or spine fusion, or whether the 3CO performed was a PSO or VCR (p ≥ 0.06). Twenty-seven (33%) patients had 1-11 reoperations (total of 44 reoperations). The most common indications for reoperation were rod breakage (n = 14), deep wound infection (n = 15), and PJK (n = 6). The 24 patients who did not achieve 2-year follow-up had a mean of 0.85 years of follow-up, and the types of early and delayed complications encountered in these 24 patients were comparable to those encountered in the patients that achieved 2-year follow-up. CONCLUSIONS Among 82 ASD patients treated with 3CO, 64 (78.0%) had at least 1 early or delayed complication (57 minor, 85 major). The most common complications were instrumentation failure, dural tear, new neurological deficit, PJK, pleural effusion, and deep wound infection. None of the assessed demographic or surgical parameters were significantly associated with the occurrence of complications. These data may prove useful for surgical planning, patient counseling, and efforts to improve the safety and cost-effectiveness of these procedures.

  View details for DOI 10.3171/2016.10.SPINE16849

  View details for PubMedID 28291402

• National Administrative Databases in Adult Spinal Deformity Surgery: A Cautionary Tale. Spine Buckland, A. J., Poorman, G., Freitag, R., Jalai, C., Klineberg, E. O., Kelly, M., Passias, P. G. 2017; 42 (16): 1248-1254

  Abstract

  Comparison between national administrative databases and a prospective multicenter physician managed database.This study aims to assess the applicability of National Administrative Databases (NADs) in adult spinal deformity (ASD). Our hypothesis is that NADs do not include comparable patients as in a physician-managed database (PMD) for surgical outcomes in adult spinal deformity.NADs such as National Inpatient Sample (NIS) and National Surgical Quality Improvement Program (NSQIP) provide large numbers of publications owing to ease of data access and lack of IRB approval requirement. These databases utilize billing codes, not clinical inclusion criteria, and have not been validated against PMDs in ASD surgery.The NIS was searched for years 2002 to 2012 and NSQIP for years 2006 to 2013 using validated spinal deformity diagnostic codes. Procedural codes (ICD-9 and CPT) were then applied to each database. A multicenter PMD including years 2008 to 2015 was used for comparison. Databases were assessed for levels fused, osteotomies, decompressed levels, and invasiveness. Database comparisons for surgical details were made in all patients, and also for patients with ≥ 5 level spinal fusions.Approximately, 37,368 NIS, 1291 NSQIP, and 737 PMD patients were identified. NADs showed an increased use of deformity billing codes over the study period (NIS doubled, 68x NSQIP, P < 0.001), but ASD remained stable in the PMD.Surgical invasiveness, levels fused and use of 3-column osteotomy (3-CO) were significantly lower for all patients in the NIS (11.4-13.7) and NSQIP databases (6.4-12.7) compared with PMD (27.5-32.3). When limited to patients with ≥5 levels, invasiveness, levels fused, and use of 3-CO remained significantly higher in the PMD compared with NADs (P < 0.001).National databases NIS and NSQIP do not capture the same patient population as is captured in PMDs in ASD. Physicians should remain cautious in interpreting conclusions drawn from these databases.4.

  View details for DOI 10.1097/BRS.0000000000002064

  View details for PubMedID 28067697

• Adult Scoliosis Deformity Surgery: Comparison of Outcomes Between One Versus Two Attending Surgeons. Spine Gomez, J. A., Lafage, V., Sciubba, D. M., Bess, S., Mundis, G. M., Liabaud, B., Hanstein, R., Shaffrey, C., Kelly, M., Ames, C., Smith, J. S., Passias, P. G., Errico, T., Schwab, F. 2017; 42 (13): 992-998

  Abstract

  Retrospective review of prospectively collected data.Assess outcomes of adult spinal deformity (ASD) surgery performed by one versus two attending surgeons.ASD centers have developed two attending teams to improve efficiency; their effects on complications and outcomes have not been reported.Patients with ASD with five or more levels fused and more than 2-year follow-up were included. Estimated blood loss (EBL), length of stay (LOS), operating room (OR) time, complications, quality of life (Health Related Quality of Life), and x-rays were analyzed. Outcomes were compared between one-surgeon (1S) and two-surgeon (2S) centers. A deformity-matched cohort was analyzed.A total of 188 patients in 1S and 77 in 2S group were included. 2S group patients were older and had worse deformity based on the Scoliosis Research Society-Schwab classification (P < 0.05). There were no significant differences in levels fused (P = 0.57), LOS (8.7 vs 8.9 days), OR time (445.9 vs 453.2 min), or EBL (2008 vs 1898 cm; P > 0.05). 2S patients had more three-column osteotomies (3CO; P < 0.001) and used less bone morphogenetic protein 2 (BMP-2; 79.9% vs 15.6%; P < 0.001). The 2S group had fewer intraoperative complications (1.3% vs 11.1%; P = 0.006). Postoperative (6 wk to 2 yr) complications were more frequent in the 2S group (4.8% vs 15.6%; P < 0.002). After matching for deformity, there were no differences in (9.1 vs 10.1 days), OR time (467.8 vs 508.4 min), or EBL (3045 vs 2247 cm; P = 0.217). 2S group used less BMP-2 (20.6% vs 84.8%; P < 0.001), had fewer intraoperative complications (P = 0.015) but postoperative complications due to instrumentation failure/pseudarthrosis were more frequent (P < 0.01).No significant differences were found in LOS, OR time, or EBL between the 1S and 2S groups, even when matching for severity of deformity. 2S group had less BMP-2 use, fewer intraoperative complications but more postoperative complications.2.

  View details for DOI 10.1097/BRS.0000000000002071

  View details for PubMedID 28098740

• Cell Saver for Adult Spinal Deformity Surgery Reduces Cost. Spine deformity Gum, J. L., Carreon, L. Y., Kelly, M. P., Hostin, R., Robinson, C., Burton, D. C., Polly, D. W., Shaffrey, C. I., LaFage, V., Schwab, F. J., Ames, C. P., Kim, H. J., Smith, J. S., Bess, R. S. 2017; 5 (4): 272-276

  Abstract

  Retrospective cohort.To determine if the use of cell saver reduces overall blood costs in adult spinal deformity (ASD) surgery.Recent studies have questioned the clinical value of cell saver during spine procedures.ASD patients enrolled in a prospective, multicenter surgical database who had complete preoperative and surgical data were identified. Patients were stratified into (1) cell saver available during surgery, but no intraoperative autologous infusion (No Infusion group), or (2) cell saver available and received autologous infusion (Infusion group).There were 427 patients in the Infusion group and 153 in the No infusion group. Patients in both groups had similar demographics. Mean autologous infusion volume was 698 mL. The Infusion group had a higher percentage of EBL relative to the estimated blood volume (42.2%) than the No Infusion group (19.6%, p < .000). Allogeneic transfusion was more common in the Infusion group (255/427, 60%) than the No Infusion group (67/153, 44%, p = .001). The number of allogeneic blood units transfused was also higher in the Infusion group (2.4) than the No Infusion group (1.7, p = .009). Total blood costs ranged from $396 to $2,146 in the No Infusion group and from $1,262 to $5,088 in the Infusion group. If the cost of cell saver blood was transformed into costs of allogeneic blood, total blood costs for the Infusion group would range from $840 to $5,418. Thus, cell saver use yielded a mean cost savings ranging from $330 to $422 (allogeneic blood averted). Linear regression showed that after an EBL of 614 mL, cell saver becomes cost-efficient.Compared to transfusing allogeneic blood, cell saver autologous infusion did not reduce the proportion or the volume of allogeneic transfusion for patients undergoing surgery for adult spinal deformity. The use of cell saver becomes cost-efficient above an EBL of 614 mL, producing a cost savings of $330 to $422.Level III.

  View details for DOI 10.1016/j.jspd.2017.01.005

  View details for PubMedID 28622903

• Retrospective analysis underestimates neurological deficits in complex spinal deformity surgery: a Scoli-RISK-1 Study. Journal of neurosurgery. Spine Kelly, M. P., Lenke, L. G., Godzik, J., Pellise, F., Shaffrey, C. I., Smith, J. S., Lewis, S. J., Ames, C. P., Carreon, L. Y., Fehlings, M. G., Schwab, F., Shimer, A. L. 2017; 27 (1): 68-73

  Abstract

  OBJECTIVE The authors conducted a study to compare neurological deficit rates associated with complex adult spinal deformity (ASD) surgery when recorded in retrospective and prospective studies. Retrospective studies may underreport neurological deficits due to selection, detection, and recall biases. Prospective studies are expensive and more difficult to perform, but they likely provide more accurate estimates of new neurological deficit rates. METHODS New neurological deficits were recorded in a prospective study of complex ASD surgeries (pSR1) with a defined outcomes measure (decrement in American Spinal Injury Association lower-extremity motor score) for neurological deficits. Using identical inclusion criteria and a subset of participating surgeons, a retrospective study was created (rSR1) and neurological deficit rates were collected. Continuous variables were compared with the Student t-test, with correction for multiple comparisons. Neurological deficit rates were compared using the Mantel-Haenszel method for standardized risks. Statistical significance for the primary outcome measure was p < 0.05. RESULTS Overall, 272 patients were enrolled in pSR1 and 207 patients were enrolled in rSR1. Inclusion criteria, defining complex spinal deformities, and exclusion criteria were identical. Sagittal Cobb measurements were higher in pSR1, although sagittal alignment was similar. Preoperative neurological deficit rates were similar in the groups. Three-column osteotomies were more common in pSR1, particularly vertebral column resection. New neurological deficits were more common in pSR1 (pSR1 17.3% [95% CI 12.6-22.2] and rSR1 9.0% [95% CI 5.0-13.0]; p = 0.01). The majority of deficits in both studies were at the nerve root level, and the distribution of level of injury was similar. CONCLUSIONS New neurological deficit rates were nearly twice as high in the prospective study than the retrospective study with identical inclusion criteria. These findings validate concerns regarding retrospective cohort studies and confirm the need for and value of carefully designed prospective, observational cohort studies in ASD.

  View details for DOI 10.3171/2016.12.SPINE161068

  View details for PubMedID 28475019

• The Health Impact of Adult Cervical Deformity in Patients Presenting for Surgical Treatment: Comparison to United States Population Norms and Chronic Disease States Based on the EuroQuol-5 Dimensions Questionnaire. Neurosurgery Smith, J. S., Line, B., Bess, S., Shaffrey, C. I., Kim, H. J., Mundis, G., Scheer, J. K., Klineberg, E., O'Brien, M., Hostin, R., Gupta, M., Daniels, A., Kelly, M., Gum, J. L., Schwab, F. J., Lafage, V., Lafage, R., Ailon, T., Passias, P., Protopsaltis, T., Albert, T. J., Riew, K. D., Hart, R., Burton, D., Deviren, V., Ames, C. P., Group, I. S. 2017; 80 (5): 716-725

  Abstract

  Although adult cervical spine deformity (ACSD) is associated with pain and disability, its health impact has not been quantified in comparison to other chronic diseases.To perform a comparative analysis of the health impact of symptomatic ACSD to US normative and chronic disease values using EQ-5D (EuroQuol-5 Dimensions questionnaire) scores.ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Baseline demographics and EQ-5D scores were collected and compared with US normative and disease state values.Of 121 ACSD patients, 115 (95%) completed the EQ-5D (60% women, mean age 61 years, previous spine surgery in 44%). Diagnoses included kyphosis with mid-cervical (63.4%), cervico-thoracic (23.5%), or thoracic (8.7%) apex and primary coronal deformity (4.3%). The mean ACSD EQ-5D index was 0.511 (standard definition = 0.224), which is 34% below the bottom 25th percentile (0.780) for similar age- and gender-matched US normative populations. Mean ACSD EQ-5D index values were worse than the bottom 25th percentile for several other disease states, including chronic ischemic heart disease (0.708), malignant breast cancer (0.708), and malignant prostate cancer (0.708). ACSD mean index values were comparable to the bottom 25th percentile values for blindness/low vision (0.543), emphysema (0.508), renal failure (0.506), and stroke (0.463). EQ-5D scores did not significantly differ based on cervical deformity type ( P = .66).The health impact of symptomatic ACSD is substantial, with negative impact across all EQ-5D domains. The mean ACSD EQ-5D index was comparable to the bottom 25th percentile values for blindness/low vision, emphysema, renal failure, and stroke.

  View details for DOI 10.1093/neuros/nyx028

  View details for PubMedID 28368524

• Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature. Global spine journal Hershman, S. H., Kunkle, W. A., Kelly, M. P., Buchowski, J. M., Ray, W. Z., Bumpass, D. B., Gum, J. L., Peters, C. M., Singhatanadgige, W., Kim, J. Y., Smith, Z. A., Hsu, W. K., Nassr, A., Currier, B. L., Rahman, R. K., Isaacs, R. E., Smith, J. S., Shaffrey, C., Thompson, S. E., Wang, J. C., Lord, E. L., Buser, Z., Arnold, P. M., Fehlings, M. G., Mroz, T. E., Riew, K. D. 2017; 7 (1 Suppl): 28S-36S

  Abstract

  Multicenter retrospective case series and review of the literature.To determine the rate of esophageal perforations following anterior cervical spine surgery.As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis.The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired.Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality.

  View details for DOI 10.1177/2192568216687535

  View details for PubMedID 28451488

  View details for PubMedCentralID PMC5400185

• Perioperative Neurologic Complications in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 564 Patients. Spine Kim, H. J., Iyer, S., Zebala, L. P., Kelly, M. P., Sciubba, D., Protopsaltis, T. S., Gupta, M., Neuman, B. J., Mundis, G. M., Ames, C. P., Smith, J. S., Hart, R., Burton, D., Klineberg, E. O. 2017; 42 (6): 420-427

  Abstract

  Prognostic study-case controlled.Describe the rate of neurologic complications in adult spinal deformity surgery and describe the effect of these complications on clinical outcomes.The incidence of neurologic complications and the risk factors for neurologic complications have not been reported in a large series of patients with adult spinal deformity (ASD). Existing series include a mixed patient cohort undergoing different types of spine surgery.Patients with ASD undergoing surgery between 2008 and 2014 were analyzed. Patients with neurologic complications were identified; demographics, operative details, and radiographic and clinical outcomes were compared. A subanalysis of those with surgical and nonsurgical (e.g., stroke) neurologic complications was performed. Statistical analysis included t tests or χ tests as appropriate and a multivariate analysis. A P value of less than 0.025 was considered significant.A total of 564 patients met the inclusion criteria. The average age was 57 years. There were a total of 116 neurologic complications in 99 patients (17.6%). There were 88 surgical procedure-related neurologic complications in 77 patients (13.7%) and 28 nonsurgical neurologic complications in 28 patients (5.0%). The most common complications were radiculopathy (30%), motor deficits (22%), mental status changes (12%), and sensory deficits (12%). Revisions (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.4) and interbody fusions (OR 2.1, 95% CI 1.4-3.2) were associated with an increased risk of neurologic complications. Decompression and osteotomies (including three-column osteotomies) did not increase the risk of neurologic complications. Patients with neurologic complications were not more likely to sustain other complications; however, they were more likely to undergo another operation during the follow-up period (OR 1.9, 95% CI 1.3-2.8).The overall incidence of neurologic complications in ASD surgery was 17.6%. The incidence of surgical neurologic complications was 13.7%. There was a higher risk of neurologic complications in revision cases and in cases in which interbody fusion was required.3.

  View details for DOI 10.1097/BRS.0000000000001774

  View details for PubMedID 27398890

• Failure of Anterior Cervical, Low-Profile, Stand-Alone Screw-Plate Devices Kelly , M., Ray , W. Kim et al (eds) Spinal Instrumentation. 2017 135-139
• The Pursuit of Excellence in Forensic Psychiatry Education Academic Psychiatry Kelly, M. 2017: 780–82

  View details for DOI 10.1007/s40596-017-0815-0

• Patient-Reported Outcomes Following the Treatment of Adult Lumbar Scoliosis Hershman , S., Gornet , M., Kelly , M. Klineberg EO (eds) Adult Lumbar Scoliosis. Cham, Switzerland, Springer International Publishing. 2017 255-266
• Impact of cost valuation on cost-effectiveness in adult spine deformity surgery. The spine journal : official journal of the North American Spine Society Gum, J. L., Hostin, R., Robinson, C., Kelly, M. P., Carreon, L. Y., Polly, D. W., Bess, R. S., Burton, D. C., Shaffrey, C. I., Smith, J. S., LaFage, V., Schwab, F. J., Ames, C. P., Glassman, S. D. 2017; 17 (1): 96-101

  Abstract

  Over the past decade, the number of adult spinal deformity (ASD) surgeries has more than doubled in the United States. The complex surgeries needed to manage ASD are associated with significant resource utilization and high cost, making them a primary target for increased scrutiny. Accordingly, it is important to not only demonstrate value in ASD surgery as clinical effectiveness but also to translate outcome assessment to cost-effectiveness.To compare the difference between Medicare allowable rates and the actual, direct hospital costs for ASD surgeries.Longitudinal cohort.Consecutive patients enrolled in an ASD database from a single institution.Short Form (SF)-6D.Consecutive patients enrolled in an ASD database from a single institution from 2008 to 2013 were identified. Direct hospital costs were collected from hospital administrative records for the entire inpatient episode of surgical care. Medicare allowable rates were calculated for the same inpatient stays using the year-appropriate Center for Medicare-Medicaid Services Inpatient Pricer Payment System Tool. The SF-6D, a utility index derived from the SF-36v1, was used to determine quality-adjusted life years (QALY). Costs and QALYs were discounted at 3.5% annually.Of 580 surgical ASD patients eligible for 2-year follow up, 346 (60%) had complete baseline and 2-year data, and 60 were Medicare beneficiaries comprising the cohort for the present study. Mean SF-6D gained is 0.10 during year 1 after surgery and 0.02 at year 2, resulting in a cumulative SF-6D gain of 0.12 over 2 years. Mean Medicare allowable rate over the 2 years is $82,050 (range $42,383 to $220,749) and mean direct cost is $99,114 (range $28,447 to $217,717). Mean cost per QALY over 2 years is $683,750 using Medicare allowable rates and $825,950 using direct costs. This difference of $17,181 between the 2 cost calculation represents a 17% difference, which was statistically significant (p<.001).There is a significant difference in direct hospital costs versus Medicare allowable rates in ASD surgery and in turn, there is a similar difference in the cost per QALY calculation. Utilizing Medicare allowable rates not only underestimates (17%) the cost of ASD surgery, but it also creates inaccurate and unrealistic expectations for researchers and policymakers.

  View details for DOI 10.1016/j.spinee.2016.08.020

  View details for PubMedID 27523283

• Results of Revision Surgery for Proximal Junctional Kyphosis Following Posterior Segmental Instrumentation: Minimum 2-Year Postrevision Follow-Up. Spine Kim, Y. C., Lenke, L. G., Bridwell, K. H., Hyun, S. J., You, K. H., Kim, Y. W., Chang, H. G., Kelly, M. P., Koester, L. A., Blanke, K. M., Bumpass, D. B. 2016; 41 (24): E1444-E1452

  Abstract

  A retrospective cohort study.The aim of this study was to evaluate radiographic and patient-reported outcomes at minimum 2 years after revision surgery for proximal junctional kyphosis (PJK), correlating these results with PJK etiology.There are no studies detailing the results of revision surgery for PJK following posterior segmental instrumentation.Thirty-two consecutive patients treated with revision surgery after PJK above posterior fusions (25 women/7 men, average age at surgery 60.6 yrs) were reviewed for radiographic and patient-reported outcomes (mean follow-up, 4.5 yrs; range, 2-10 yrs). Patients were subdivided into fracture (F) and nonfracture (NF) groups on the basis of PJK etiology.Radiographic severity of PJK improved significantly with revision surgery and was maintained at ultimate follow-up (P < 0.001). However, initial sagittal vertical axis (SVA) correction was not maintained through ultimate follow-up (P = 0.04). There were significant postrevision improvements in mean Oswestry scores (P < 0.001) and SRS total scores (P < 0.001) in all patients. In patients with pelvic incidence-lumbar lordosis (PI-LL) mismatch < 11°, final PJK measurement was smaller than in patients with mismatch ≥11° (9.4° vs. 19.8°, P = 0.009). Six patients (19%) developed new postrevision PJK, with two (6%) requiring additional surgery. Patients who sustained PJK through a fracture had greater improvements in Oswestry (P = 0.004), total SRS (P = 0.04), pain (P < 0.001), and satisfaction (P = 0.05) scores, although the fracture patients had less maintained SVA correction (P = 0.002).Revision surgery for PJK following posterior instrumentation achieved acceptable radiographic and clinical outcomes at minimum 2-year follow-up. Patients with PI-LL mismatch <11° experienced more ultimate PJK correction than patients with mismatch ≥11°. Although the NF group experienced more sustained correction of sagittal balance, the F group reported greater improvements in patient-reported outcomes. Ultimate clinical outcomes after revision surgery for PJK were similar between patients with and without compression fractures.3.

  View details for DOI 10.1097/BRS.0000000000001664

  View details for PubMedID 27128389

• Fractures of the axis: a review of pediatric, adult, and geriatric injuries. Current reviews in musculoskeletal medicine Gornet, M. E., Kelly, M. P. 2016; 9 (4): 505-512

  Abstract

  Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a "Hangman's Fracture." Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.

  View details for DOI 10.1007/s12178-016-9368-1

  View details for PubMedID 27686572

  View details for PubMedCentralID PMC5127948

• Baseline Patient-Reported Outcomes Correlate Weakly With Radiographic Parameters: A Multicenter, Prospective NIH Adult Symptomatic Lumbar Scoliosis Study of 286 Patients. Spine Chapman, T. M., Baldus, C. R., Lurie, J. D., Glassman, S. D., Schwab, F. J., Shaffrey, C. I., Lafage, V., Boachie-Adjei, O., Kim, H. J., Smith, J. S., Crawford, C. H., Lenke, L. G., Buchowski, J. M., Edwards, C., Koski, T., Parent, S., Lewis, S., Kang, D. G., McClendon, J., Metz, L., Zebala, L. P., Kelly, M. P., Spratt, K. F., Bridwell, K. H. 2016; 41 (22): 1701-1708

  Abstract

  Prospective, cross-sectional study.The aim of the study was to determine which radiographic parameters drive patient-reported outcomes (PROs) in primary presentation adult symptomatic lumbar scoliosis (ASLS).Previous literature suggests correlations between PROs and sagittal plane deformity (sagittal vertical axis [SVA], pelvic incidence-lumbar lordosis [PI-LL] mismatch, pelvic tilt [PT]). Prior work included revision and primary adult spinal deformity patients. The present study addresses only primary presentation ASLS.Prospective baseline data were analyzed on 286 patients enrolled in an NIH RO1 clinical trial by nine centers from 2010 to 2014.40 to 80 years old, lumbar Cobb (LC) 30° or higher and Scoliosis Research Society-23 score 4.0 or less in Pain, Function or Self-Image domains, or Oswestry Disability Index (ODI) 20 or higher. Patients were primary presentation (no prior spinal deformity surgery) and had complete baseline data: standing coronal/sagittal 36" radiographs and PROs (ODI, Scoliosis Research Society-23, Short Form-12). Correlation coefficients were calculated to evaluate relations between radiographic parameters and PROs for the study population and a subset of patients with ODI 40 or higher. Analysis of variance was used to identify differences in PROs for radiographic modifier groups.Mean age was 60.3 years. Mean spinopelvic parameters were: LL = -39.2°; SVA = 3.1 cm; sacral slope = 32.5°; PT = 23.9°; PI-LL mismatch = 16.8°. Only weak correlations (0.2-0.4) were identified between population sacral slope, SVA and SVA modifiers, and SRS function. SVA and SVA modifiers were weakly associated with ODI. Although there were more correlations in subset analysis of high-symptom patients, all were weak. Analysis of variance identified significant differences in ODI reported by SVA modifier groups.In primary presentation patients with ASLS and a subset of "high-symptom" patients (ODI ≥ 40), only weak associations between baseline PROs and radiographic parameters were identified. For this patient population, these results suggest regional radiographic parameters (LC, LL, PT, PI-LL mismatch) are not drivers of PROs and cannot be used to extrapolate effect on patient-perceived pathology.2.

  View details for DOI 10.1097/BRS.0000000000001613

  View details for PubMedID 27831984

  View details for PubMedCentralID PMC5119760

• Validity, Reliability, and Responsiveness of SRS-7 as an Outcomes Assessment Instrument for Operatively Treated Patients With Adult Spinal Deformity. Spine Jain, A., Lafage, V., Kelly, M. P., Hassanzadeh, H., Neuman, B. J., Sciubba, D. M., Bess, S., Shaffrey, C. I., Ames, C. P., Scheer, J. K., Burton, D., Gupta, M. C., Hart, R., Hostin, R. A., Kebaish, K. M. 2016; 41 (18): 1463-8

  Abstract

  A retrospective analysis.The aim of our study was to compare the normality, concurrent validity, internal consistency, responsiveness, and dimensionality of an item response theory-derived seven-question instrument (SRS-7), against the Scoliosis Research Society-22r (SRS-22r) questionnaire in operatively treated patients with adult spinal deformity (ASD).Compared with SRS-22r, SRS-7 (which has been validated in operatively treated patients with adolescent idiopathic scoliosis) has advantages of being short, unidimensional, and linear.A prospective database of ASD patients was queried for patients 18 years or older who were operatively treated, and who answered pre- and postoperative (at 2-year follow-up) SRS-22r questions (n = 276). Corresponding SRS-7 scores were calculated using answers to SRS-22r items 1, 4, 6, 10, 18, 19, and 20. Significance was set at a P value less than 0.01.SRS-7 and SRS-22r were normally distributed preoperatively but not postoperatively. SRS-7 and SRS-22r scores had high correlation both preoperatively (r = 0.76, P < 0.01) and postoperatively (r = 0.83, P < 0.01). The internal consistency reliability Cronbach α values were 0.61 (SRS-7) and 0.83 (SRS-22r) preoperatively and 0.91 (SRS-7) and 0.95 (SRS-22r) postoperatively. SRS-7 was found to be more responsive than SRS-22r with measures of effect size: Cohen d = 1.21 versus 1.13, Hedge g = 1.21 versus 1.13, and effect size correlation r = 0.52 versus 0.49. Iterative principal factor analysis of pre- and postoperative scores showed the presence of one dominant latent factor in SRS-7 (unidimensionality) and four latent factors in SRS-22r (multidimensionality).SRS-7 is a valid, reliable, responsive, and unidimensional instrument, which can be used as a short-form alternative to the SRS-22r for assessing global changes in patient-reported outcomes over time in patients with ASD.3.

  View details for DOI 10.1097/BRS.0000000000001540

  View details for PubMedID 26937607

• Reliability of the revised Scoliosis Research Society-22 and Oswestry Disability Index (ODI) questionnaires in adult spinal deformity when administered by telephone SPINE JOURNAL Bokshan, S. L., Godzik, J., Dalton, J., Jaffe, J., Lenke, L. G., Kelly, M. P. 2016; 16 (9): 1042-1046

  Abstract

  The non-response rates are as high as 20% to 50% after 5 years of follow-up in adult spinal deformity (ASD) surgery. Minimizing loss to follow-up is essential to protect the quality of data in long-term studies. Phone and internet administration of outcomes instruments has grown in popularity and has been found to not only provide a convenient way of collecting data, but also show improved response rates.The study aimed to examine the reliability of the revised Scoliosis Research Society-22 (SRS-22r) and the Oswestry Disability Index (ODI) questionnaires in ASD patients when administered by telephone.This is a single-center, randomized crossover phone validation of ASD patients.The study included ASD patients presenting to a tertiary spine care center.The outcome measures were ODI and SRS-22r.Forty-nine patients (mean age: 55.7 years) with ASD were randomized in a 1:1 ratio to either phone completion of the SRS-22r and ODI followed by in-office completion, or to in-office completion followed by phone completion. An interval of 2 to 4 weeks was placed between administrations of each version. A paired t test was used to assess the difference between the written and phone versions, and intraclass correlation coefficients were used to assess homogeneity. Finally, goodness-of-fit testing was used to assess version preference.There was no significant difference between the phone and in-office versions of the SRS-22r (p=.174) or the ODI (p=.320). The intraclass correlation coefficients of the SRS-22r and ODI were 0.91 and 0.86, respectively. Completion over the phone was the most popular option (57% preferred phone, 29% preferred in-office, and 14% had no preference).Phone administration of the SRS-22r and ODI to ASD patients provides a convenient and reliable tool for reducing loss of follow-up data.

  View details for DOI 10.1016/j.spinee.2016.03.022

  View details for Web of Science ID 000386368700034

  View details for PubMedID 26997110

  View details for PubMedCentralID PMC5026890

• Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. Journal of neurosurgery. Spine Smith, J. S., Klineberg, E., Lafage, V., Shaffrey, C. I., Schwab, F., Lafage, R., Hostin, R., Mundis, G. M., Errico, T. J., Kim, H. J., Protopsaltis, T. S., Hamilton, D. K., Scheer, J. K., Soroceanu, A., Kelly, M. P., Line, B., Gupta, M., Deviren, V., Hart, R., Burton, D. C., Bess, S., Ames, C. P. 2016; 25 (1): 1-14

  Abstract

  OBJECTIVE Although multiple reports have documented significant benefit from surgical treatment of adult spinal deformity (ASD), these procedures can have high complication rates. Previously reported complications rates associated with ASD surgery are limited by retrospective design, single-surgeon or single-center cohorts, lack of rigorous data on complications, and/or limited follow-up. Accurate definition of complications associated with ASD surgery is important and may serve as a resource for patient counseling and efforts to improve the safety of patient care. The authors conducted a study to prospectively assess the rates of complications associated with ASD surgery with a minimum 2-year follow-up based on a multicenter study design that incorporated standardized data-collection forms, on-site study coordinators, and regular auditing of data to help ensure complete and accurate reporting of complications. In addition, they report age stratification of complication rates and provide a general assessment of factors that may be associated with the occurrence of complications. METHODS As part of a prospective, multicenter ASD database, standardized forms were used to collect data on surgery-related complications. On-site coordinators and central auditing helped ensure complete capture of complication data. Inclusion criteria were age older than 18 years, ASD, and plan for operative treatment. Complications were classified as perioperative (within 6 weeks of surgery) or delayed (between 6 weeks after surgery and time of last follow-up), and as minor or major. The primary focus for analyses was on patients who reached a minimum follow-up of 2 years. RESULTS Of 346 patients who met the inclusion criteria, 291 (84%) had a minimum 2-year follow-up (mean 2.1 years); their mean age was 56.2 years. The vast majority (99%) had treatment including a posterior procedure, 25% had an anterior procedure, and 19% had a 3-column osteotomy. At least 1 revision was required in 82 patients (28.2%). A total of 270 perioperative complications (145 minor; 125 major) were reported, with 152 patients (52.2%) affected, and a total of 199 delayed complications (62 minor; 137 major) were reported, with 124 patients (42.6%) affected. Overall, 469 complications (207 minor; 262 major) were documented, with 203 patients (69.8%) affected. The most common complication categories included implant related, radiographic, neurological, operative, cardiopulmonary, and infection. Higher complication rates were associated with older age (p = 0.009), greater body mass index (p ≤ 0.031), increased comorbidities (p ≤ 0.007), previous spine fusion (p = 0.029), and 3-column osteotomies (p = 0.036). Cases in which 2-year follow-up was not achieved included 2 perioperative mortalities (pulmonary embolus and inferior vena cava injury). CONCLUSIONS This study provides an assessment of complications associated with ASD surgery based on a prospective, multicenter design and with a minimum 2-year follow-up. Although the overall complication rates were high, in interpreting these findings, it is important to recognize that not all complications are equally impactful. This study represents one of the most complete and detailed reports of perioperative and delayed complications associated with ASD surgery to date. These findings may prove useful for treatment planning, patient counseling, benchmarking of complication rates, and efforts to improve the safety and cost-effectiveness of patient care.

  View details for DOI 10.3171/2015.11.SPINE151036

  View details for PubMedID 26918574

• Adult Spinal Deformity Surgeons Are Unable to Accurately Predict Postoperative Spinal Alignment Using Clinical Judgment Alone. Spine deformity Ailon, T., Scheer, J. K., Lafage, V., Schwab, F. J., Klineberg, E., Sciubba, D. M., Protopsaltis, T. S., Zebala, L., Hostin, R., Obeid, I., Koski, T., Kelly, M. P., Bess, S., Shaffrey, C. I., Smith, J. S., Ames, C. P. 2016; 4 (4): 323-329

  Abstract

  Adult spinal deformity (ASD) surgery seeks to reduce disability and improve quality of life through restoration of spinal alignment. In particular, correction of sagittal malalignment is correlated with patient outcome. Inadequate correction of sagittal deformity is not infrequent. The present study assessed surgeons' ability to accurately predict postoperative alignment.Seventeen cases were presented with preoperative radiographic measurements, and a summary of the operation as performed by the treating physician. Surgeon training, practice characteristics, and use of surgical planning software was assessed. Participants predicted if the surgical plan would lead to adequate deformity correction and attempted to predict postoperative radiographic parameters including sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence to lumbar lordosis mismatch (PI-LL), thoracic kyphosis (TK).Seventeen surgeons participated: 71% within 0 to 10 years of practice; 88% devote >25% of their practice to deformity surgery. Surgeons accurately judged adequacy of the surgical plan to achieve correction to specific thresholds of SVA 69% ± 8%, PT 68% ± 9%, and PI-LL 68% ± 11% of the time. However, surgeons correctly predicted the actual postoperative radiographic parameters only 42% ± 6% of the time. They were more successful at predicting PT (61% ± 10%) than SVA (45% ± 8%), PI-LL (26% ± 11%), or TK change (35% ± 21%; p < .05). Improved performance correlated with greater focus on deformity but not number of years in practice or number of three-column osteotomies performed per year.Surgeons failed to correctly predict the adequacy of the proposed surgical plan in approximately one third of presented cases. They were better at determining whether a surgical plan would achieve adequate correction than predicting specific postoperative alignment parameters. Pelvic tilt and SVA were predicted with the greatest accuracy.

  View details for DOI 10.1016/j.jspd.2016.02.003

  View details for PubMedID 27927523

• Spinolaminar Line Test as a Screening Tool for C1 Stenosis. Global spine journal Oshima, Y., Kelly, M. P., Song, K. S., Park, M. S., Chuntarapas, T., Vo, K. D., Yeom, J. S., Takeshita, K., Riew, K. D. 2016; 6 (4): 370-4

  Abstract

  Study Design Retrospective cohort. Objective To clarify the sensitivity of C3-C2 spinolaminar line test as a screening tool for the stenosis of C1 space available for the cord (SAC). Methods Spine clinic records from April 2005 to August 2011 were reviewed. The C1 SAC was measured on lateral radiographs, and the relative positions between a C1 posterior arch and the C3-C2 spinolaminar line were examined and considered "positive" when the C1 ring lay ventral to the line. Computed tomography (CT) scans and magnetic resonance imaging (MRI) were utilized to measure precise diameters of C1 and C2 SAC and to check the existence of spinal cord compression. Results Four hundred eighty-seven patients were included in this study. There were 246 men and 241 women, with an average age of 53 years (range: 18 to 86). The mean SAC at C1 on radiographs was 21.2 mm (range: 13.5 to 28.2). Twenty-one patients (4.3%) were positive for the spinolaminar line test; all of these patients had C1 SAC of 19.4 mm or less. Eight patients (1.6%) had C1 SAC smaller than C2 on CT examination; all of these patients had a positive spinolaminar test, with high sensitivity (100%) and specificity (97%). MRI analysis revealed that two of the eight patients with a smaller C1 SAC had spinal cord compression at the C1 level. Conclusion Although spinal cord compression at the level of atlas without instability is a rare condition, the spinolaminar line can be used as a screening of C1 stenosis.

  View details for DOI 10.1055/s-0035-1564418

  View details for PubMedID 27190740

  View details for PubMedCentralID PMC4868590

• Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity: A Prospective, Multicenter, Propensity-Matched Cohort Assessment With Minimum 2-Year Follow-up. Neurosurgery Smith, J. S., Lafage, V., Shaffrey, C. I., Schwab, F., Lafage, R., Hostin, R., OʼBrien, M., Boachie-Adjei, O., Akbarnia, B. A., Mundis, G. M., Errico, T., Kim, H. J., Protopsaltis, T. S., Hamilton, D. K., Scheer, J. K., Sciubba, D., Ailon, T., Fu, K. G., Kelly, M. P., Zebala, L., Line, B., Klineberg, E., Gupta, M., Deviren, V., Hart, R., Burton, D., Bess, S., Ames, C. P. 2016; 78 (6): 851-61

  Abstract

  High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed.To compare outcomes of operative and nonoperative treatment for ASD.This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence-to-lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up.Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence-to-lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications.Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability.ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisMCID, minimal clinically important differenceNRS, numeric rating scaleODI, Oswestry Disability IndexPI, pelvic incidenceSF-36, Short Form-36SRS-22r, Scoliosis Research Society-22rSVA, sagittal vertical axis.

  View details for DOI 10.1227/NEU.0000000000001116

  View details for PubMedID 26579966

• Magnetic Resonance Imaging Biomarker of Axon Loss Reflects Cervical Spondylotic Myelopathy Severity. Spine Murphy, R. K., Sun, P., Xu, J., Wang, Y., Sullivan, S., Gamble, P., Wagner, J., Wright, N. N., Dorward, I. G., Riew, D., Santiago, P., Kelly, M. P., Trinkaus, K., Ray, W. Z., Song, S. K. 2016; 41 (9): 751-6

  Abstract

  A prospective cohort study.In this study, we employed diffusion basis spectrum imaging (DBSI) to quantitatively assess axon/myelin injury, cellular inflammation, and axonal loss of cervical spondylotic myelopathy (CSM) spinal cords.A major shortcoming in the management of CSM is the lack of an effective diagnostic approach to stratify treatments and to predict outcomes. No current clinical diagnostic imaging approach is capable of accurately reflecting underlying spinal cord pathologies.Seven patients with mild (mJOA ≥15), five patients with moderate (14≥mJOA ≥11), and two patients with severe (mJOA <11) CSM were prospectively enrolled. Given the low number of severe patients, moderate and severe patients were combined for comparison with seven age-matched controls and statistical analysis. We employed the newly developed DBSI to quantitatively measure axon and myelin injury, cellular inflammation, and axonal loss.Median DBSI-inflammation volume is similar in control (266 μL) and mild CSM (171 μL) subjects, with a significant overlap of the middle 50% of observations (quartile 3 - quartile 1). This was in contrast to moderate CSM subjects that had higher DBSI-inflammation volumes (382 μL; P = 0.033). DBSI-axon volume shows a strong correlation with clinical measures (r = 0.79 and 0.87, P = 1.9 x 10-5 and 2 x 10-4 for mJOA and MDI, respectively). In addition to axon and myelin injury, our findings suggest that both inflammation and axon loss contribute to neurological impairment. Most strikingly, DBSI-derived axon volume declines as severity of impairment increases.DBSI-quantified axonal loss may be an imaging biomarker to predict functional recovery following decompression in CSM. Our results demonstrate an increase of about 60% in the odds of impairment relative to the control for each decrease of 100 μL in axon volume.3.

  View details for DOI 10.1097/BRS.0000000000001337

  View details for PubMedID 26650876

  View details for PubMedCentralID PMC4853237

• Patient Factors That Influence Decision Making: Randomization Versus Observational Nonoperative Versus Observational Operative Treatment for Adult Symptomatic Lumbar Scoliosis. Spine Neuman, B. J., Baldus, C., Zebala, L. P., Kelly, M. P., Shaffrey, C., Edwards, C., Koski, T., Schwab, F., Glassman, S., Parent, S., Lewis, S., Lenke, L. G., Buchowski, J. M., Smith, J. S., Crawford, C. H., Kim, H. J., Lafage, V., Lurie, J., Carreon, L., Bridwell, K. H. 2016; 41 (6): E349-58

  Abstract

  A prospective study with randomized and observational cohorts.The aim of this study was to determine baseline variables affecting adult symptomatic lumbar scoliosis (ASLS) decision making to participate in randomization (RAND), observational nonsurgical (OBS-NS), or observational surgical (OBS-S) cohorts.Multiple factors play a key role in a patient's decision to be randomized or to choose an OBS-NS or OBS-S course for ASLS. Studies evaluating these factors are limited.Eligible candidates (patients with ASLS and no prior spinal fusion deformity surgery) from 9 centers participated in a RAND, OBS-NS, or OBS-S cohort study. Baseline variables (demographics, socioeconomics, patient-reported outcomes [PROs], Functional Treadmill Test, radiographs) were analyzed.Two hundred ninety-five patients were enrolled: 67 RAND, 115 OBS-NS, 113 OBS-S. Subanalysis of older patients (60-80 years) found 54% of OBS-NS had college degrees compared with 82% of RAND and 71% of OBS-S (P = 0.010). Patients deciding to be part of a RAND cohort have similar clinical characteristics to the OBS-S cohort. OBS-S had more symptomatic spinal stenosis (57% vs. 39%, P = 0.029) and worse scores than OBS-NS on the basis of PROs (Back Pain Numerical Rating Scale [NRS 6.3 vs. 5.5, P = 0.007]; Scoliosis Research Society [SRS] Pain [2.8 vs. 3.0, P = 0.018], Function [3.1 vs. 3.4, P = 0.019] and Self-Image [2.7 vs. 3.1, P = 0.002]; Oswestry Disability Index (ODI) [36.9 vs. 31.8, P = 0.029]; post-Treadmill back [5.8 vs. 4.4, P = 0.002] and leg [4.3 vs. 3.1, P = 0.037] pain NRS and larger lumbar coronal Cobb angles (56.5 degrees vs. 48.8 degrees, P < 0.001). RAND had more baseline motor deficits (10.4% vs. 1.7%, P = 0.036) and worse scores than OBS-NS on the basis of ODI (38.8 vs. 31.8, P = 0.006), SRS Function [3.1 vs. 3.4, P = 0.034], and Self-Image [2.7 vs. 3.1, P = 0.007].Patients with worse PROs, more back pain, more back and leg pain with ambulation, and larger lumbar Cobb angles are more inclined to select surgical over nonsurgical management.

  View details for DOI 10.1097/BRS.0000000000001222

  View details for PubMedID 26571162

  View details for PubMedCentralID PMC4792651

• Multicenter Comparison of 3D Spinal Measurements Using Surface Topography With Those From Conventional Radiography. Spine deformity Knott, P., Sturm, P., Lonner, B., Cahill, P., Betsch, M., McCarthy, R., Kelly, M., Lenke, L., Betz, R. 2016; 4 (2): 98-103

  Abstract

  In pediatric spinal deformity the gold standard for curve surveillance remains standing full-column radiographs, but repeated exposure to ionizing radiation motivates us to look for nonradiographic solutions. This study tests a modern system of surface topography (ST) to determine whether it is reliable and reproducible.Patients from 6 pediatric spinal deformity clinics were recruited for enrollment. Inclusion criteria were age 8-18; diagnosis of scoliosis measuring ≥10 and <50 degrees or increased kyphosis of ≥45 degrees. Standing radiographs and ST scans (DIERS Formetric, Diers Medical Systems, Chicago, IL) were obtained on all patients and then measured and compared. A single investigator using a validated electronic measurement tool performed all radiographic measurements. Analysis of reproducibility and comparison of ST and radiographs were done.A total of 193 patients were enrolled (148 F [77%]). The mean age was 13.25 years (range 8-18). The scoliosis magnitude was as follows: thoracic average 22.7 ± 10 degrees; lumbar average 19.6 ± 9 degrees. The kyphosis magnitude was 54.0 ± 11 degrees. The reproducibility for each ST parameter for 3 repeated scans was strong (interclass correlation = 0.855-0.944). Comparison to radiographic measurements was strong in the thoracic (r = 0.7) and moderate in the lumbar curve (r = 0.5). There was an average difference of 5.8 degrees in the thoracic spine and 8.8 degrees in the lumbar spine between ST Cobb angle estimates and radiographs. Thoracic kyphosis also had a strong correlation (r = 0.8) with radiographs.Although the results are intended to measure similar aspects of deformity as the traditional Cobb angle, the measurement is not intended to be an exact estimation. The utility of ST is in the reproducible quantification of deformity after the initial radiograph has been taken. This has the potential to make longitudinal assessment of change in deformity without serial radiographs.

  View details for DOI 10.1016/j.jspd.2015.08.008

  View details for PubMedID 27927552

• Comparison of spinal deformity in children with Chiari I malformation with and without syringomyelia: matched cohort study. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Godzik, J., Dardas, A., Kelly, M. P., Holekamp, T. F., Lenke, L. G., Smyth, M. D., Park, T. S., Leonard, J. R., Limbrick, D. D. 2016; 25 (2): 619-26

  Abstract

  To describe curve patterns in patients with Chiari malformation I (CIM) without syringomyelia, and compare to patients with Chiari malformation with syringomyelia (CIM + SM).Review of medical records from 2000 to 2013 at a single institution was performed to identify CIM patients with scoliosis. Patients with CIM were matched (1:1) by age and gender to CIM + SM. Radiographic curve patterns, MRI-based craniovertebral junction parameters, and associated neurological signs were compared between the two cohorts.Eighteen patients with CIM-associated scoliosis in the absence of syringomyelia were identified; 14 (78 %) were female, with mean age of 11.5 ± 4.5 years. Mean tonsillar descent was 9.9 ± 4.1 mm in the CIM group and 9.1 ± 3.0 mm in the CIM + SM group (p = 0.57). Average syrinx diameter in the CIM + SM group was 9.0 ± 2.7 mm. CIM patients demonstrated less severe scoliotic curves (32.1° vs. 46.1°, p = 0.04), despite comparable thoracic kyphosis (43.7° vs. 49.6°, p = 0.85). Two (11 %) patients with CIM demonstrated thoracic apex left deformities compared to 9/18 (50 %) in the CIM + SM cohort (p = 0.01). Neurological abnormalities were only observed in the group with syringomyelia (6/18, or 33 %; p = 0.007).In the largest series specifically evaluating CIM and scoliosis, we found that these patients appear to present with fewer atypical curve features, with less severe scoliotic curves, fewer apex left curves, and fewer related neurological abnormalities than CIM + SM. Notably, equivalent thoracic kyphosis was observed in both groups. Future studies are needed to better understand pathogenesis of spinal deformity in CIM with and without SM.

  View details for DOI 10.1007/s00586-015-4011-1

  View details for PubMedID 25981206

  View details for PubMedCentralID PMC4648712

• The Health Impact of Symptomatic Adult Spinal Deformity: Comparison of Deformity Types to United States Population Norms and Chronic Diseases. Spine Bess, S., Line, B., Fu, K. M., McCarthy, I., Lafage, V., Schwab, F., Shaffrey, C., Ames, C., Akbarnia, B., Jo, H., Kelly, M., Burton, D., Hart, R., Klineberg, E., Kebaish, K., Hostin, R., Mundis, G., Mummaneni, P., Smith, J. S. 2016; 41 (3): 224-33

  Abstract

  A retrospective analysis of a prospective, multicenter database.The aim of this study was to evaluate the health impact of symptomatic adult spinal deformity (SASD) by comparing Standard Form Version 2 (SF-36) scores for SASD with United States normative and chronic disease values.Recent data have identified radiographic parameters correlating with poor health-related quality of life for SASD. Disability comparisons between SASD patients and patients with chronic diseases may provide further insight to the disease burden caused by SASD.Consecutive SASD patients, with no history of spine surgery, were enrolled into a multicenter database and evaluated for type and severity of spinal deformity. Baseline SF-36 physical component summary (PCS) and mental component summary (MCS) values for SASD patients were compared with reported U.S. normative and chronic disease SF-36 scores. SF-36 scores were reported as normative-based scores (NBS) and evaluated for minimally clinical important difference (MCID).Between 2008 and 2011, 497 SASD patients were prospectively enrolled and evaluated. Mean PCS for all SASD was lower than U.S. total population (ASD = 40.9; US = 50; P < 0.05). Generational decline in PCS for SASD patients with no other reported comorbidities was more rapid than U.S. norms (P < 0.05). PCS worsened with lumbar scoliosis and increasing sagittal vertical axis (SVA). PCS scores for patients with isolated thoracic scoliosis were similar to values reported by individuals with chronic back pain (45.5 vs 45.7, respectively; P > 0.05), whereas patients with lumbar scoliosis combined with severe sagittal malalignment (SVA >10 cm) demonstrated worse PCS scores than values reported by patients with limited use of arms and legs (24.7 vs 29.1, respectively; P < 0.05).SASD is a heterogeneous condition that, depending upon the type and severity of the deformity, can have a debilitating impact on health often exceeding the disability of more recognized chronic diseases. Health care providers must be aware of the types of SASD that correlate with disability to facilitate appropriate diagnosis, treatment, and research efforts.3.

  View details for DOI 10.1097/BRS.0000000000001202

  View details for PubMedID 26571174

  View details for PubMedCentralID PMC4718181

• Effectiveness of preoperative autologous blood donation for protection against allogeneic blood exposure in adult spinal deformity surgeries: a propensity-matched cohort analysis. Journal of neurosurgery. Spine Kelly, M. P., Zebala, L. P., Kim, H. J., Sciubba, D. M., Smith, J. S., Shaffrey, C. I., Bess, S., Klineberg, E., Mundis, G., Burton, D., Hart, R., Soroceanu, A., Schwab, F., Lafage, V. 2016; 24 (1): 124-30

  Abstract

  The goal of this study was to examine the effectiveness of preoperative autologous blood donation (PABD) in adult spinal deformity (ASD) surgery.Patients undergoing single-stay ASD reconstructions were identified in a multicenter database. Patients were divided into groups according to PABD (either PABD or NoPABD). Propensity weighting was used to create matched cohorts of PABD and NoPABD patients. Allogeneic (ALLO) exposure, autologous (AUTO) wastage (unused AUTO), and complication rates were compared between groups.Four hundred twenty-eight patients were identified as meeting eligibility criteria. Sixty patients were treated with PABD, of whom 50 were matched to 50 patients who were not treated with PABD (NoPABD). Nearly one-third of patients in the PABD group (18/60, 30%) did not receive any autologous transfusion and donated blood was wasted. In 6 of these cases (6/60, 10%), patients received ALLO blood transfusions without AUTO. In 9 cases (9/60, 15%), patients received ALLO and AUTO blood transfusions. Overall rates of transfusion of any type were similar between groups (PABD 70% [42/60], NoPABD 75% [275/368], p = 0.438). Major and minor in-hospital complications were similar between groups (Major PABD 10% [6/60], NoPABD 12% [43/368], p = 0.537; Minor PABD 30% [18/60], NoPABD 24% [87/368], p = 0.499). When controlling for potential confounders, PABD patients were more likely to receive some transfusion (OR 15.1, 95% CI 2.1-106.7). No relationship between PABD and ALLO blood exposure was observed, however, refuting the concept that PABD is protective against ALLO blood exposure. In the matched cohorts, PABD patients were more likely to sustain a major perioperative cardiac complication (PABD 8/50 [16%], NoPABD 1/50 [2%], p = 0.046). No differences in rates of infection or wound-healing complications were observed between cohorts.Preoperative autologous blood donation was associated with a higher probability of perioperative transfusions of any type in patients with ASD. No protective effect of PABD against ALLO blood exposure was observed, and no risk of perioperative infectious complications was observed in patients exposed to ALLO blood only. The benefit of PABD in patients with ASD remains undefined.

  View details for DOI 10.3171/2015.4.SPINE141329

  View details for PubMedID 26407086

  View details for PubMedCentralID PMC4701383

• Complications and Rates of Subsequent Lumbar Surgery Following Lumbar Total Disc Arthroplasty and Lumbar Fusion. Spine Eliasberg, C. D., Kelly, M. P., Ajiboye, R. M., SooHoo, N. F. 2016; 41 (2): 173-81

  Abstract

  Retrospective analysis.To examine complications and rates of subsequent surgery following lumbar spinal fusion (LF) and lumbar total disc arthroplasty (TDA) at up to 5-year follow-up.LF is commonly used in the management of degenerative disc disease causing pain refractory to nonoperative management. Lumbar TDA was developed as an alternative to fusion with the theoretical advantage of reducing rates of adjacent segment pathology and reoperation. Most prior reports comparing these 2 interventions have come from industry-sponsored investigational device exemption trials and no large-scale administrative database comparisons exist.The California Office of Statewide Health Planning and Development discharge database was queried for patients aged 18 to 65 years undergoing lumbar TDA and LF for degenerative disc disease from 2004 to 2010. Patient characteristics were collected, and rates of complications and readmission were identified. Rates of repeat lumbar surgery were calculated at 90-day and 1-, 3-, and 5-year follow-up intervals.A total of 52,877 patients met the inclusion criteria (LF = 50,462, TDA = 2415). Wound infections were more common following LF than TDA (1.03% vs. 0.25%, P < 0.001). Rates of subsequent lumbar surgery at 90-day and 1-year follow-up were lower with lumbar TDA than LF (90-day-TDA: 2.94% vs. LF: 4.01%, P = 0.007; 1-yr-TDA: 3.46% vs. LF: 4.78%, P = 0.009). However, there were no differences in rates of subsequent lumbar surgery between the 2 groups at 3-year and 5-year follow-up.Lumbar TDA was associated with fewer early reoperations, though beyond 1 year, rates of reoperation were similar. Lumbar TDA may be associated with fewer acute infections, though this may be approach related and unrelated to the device itself.3.

  View details for DOI 10.1097/BRS.0000000000001180

  View details for PubMedID 26751061

  View details for PubMedCentralID PMC4710859

• A Comprehensive Review of Complication Rates After Surgery for Adult Deformity: A Reference for Informed Consent. Spine deformity Sciubba, D. M., Yurter, A., Smith, J. S., Kelly, M. P., Scheer, J. K., Goodwin, C. R., Lafage, V., Hart, R. A., Bess, S., Kebaish, K., Schwab, F., Shaffrey, C. I., Ames, C. P. 2015; 3 (6): 575-594

  Abstract

  An up-to-date review of recent literatures and a comprehensive reference for informed consent specific to ASD complications is lacking. The goal of the present study was to determine current complication rates after ASD surgery, in order to provide a reference for informed consent as well as to determine differences between three-column and non-three-column osteotomy procedures to aid in shared decision making.A review of the literature was conducted using the PubMed database. Randomized controlled trials, nonrandomized trials, cohort studies, case-control studies, and case series providing postoperative complications published in 2000 or later were included. Complication rates were recorded and calculated for perioperative (both major and minor) and long-term complication rates. Postoperative outcomes were all stratified by surgical procedure (ie, three-column osteotomy and non-three-column osteotomy).Ninety-three articles were ultimately eligible for analysis. The data of 11,692 patients were extracted; there were 3,646 complications, mean age at surgery was 53.3 years (range: 25-77 years), mean follow-up was 3.49 years (range: 6 weeks-9.7 years), estimated blood loss was 2,161 mL (range: 717-7,034 mL), and the overall mean complication rate was 55%. Specifically, major perioperative complications occurred at a mean rate of 18.5%, minor perioperative complications occurred at a mean rate of 15.7%, and long-term complications occurred at a mean rate of 20.5%. Furthermore, three-column osteotomy resulted in a higher overall complication rate and estimated blood loss than non-three-column osteotomy.A review of recent literatures providing complication rates for ASD surgery was performed, providing the most up-to-date incidence of early and late complications. Providers may use such data in helping to counsel patients of the literature-supported complication rates of such procedures despite the planned benefits, thus obtaining a more thorough informed consent.

  View details for DOI 10.1016/j.jspd.2015.04.005

  View details for PubMedID 27927561

• Preoperative opioid strength may not affect outcomes of anterior cervical procedures: a post hoc analysis of 2 prospective, randomized trials. Journal of neurosurgery. Spine Kelly, M. P., Anderson, P. A., Sasso, R. C., Riew, K. D. 2015; 23 (4): 484-9

  Abstract

  The aim of this study is to evaluate the relationship between preoperative opioid strength and outcomes of anterior cervical decompressive surgery.A retrospective cohort of 1004 patients enrolled in 1 of 2 investigational device exemption studies comparing cervical total disc arthroplasty (TDA) and anterior cervical discectomy and fusion (ACDF) for single-level cervical disease causing radiculopathy or myelopathy was selected. At a preoperative visit, opioid use data, Neck Disability Index (NDI) scores, 36-Item Short-Form Health Survey (SF-36) scores, and numeric rating scale scores for neck and arm pain were collected. Patients were divided into strong (oxycodone/morphine/meperidine), weak (codeine/propoxyphene/hydrocodone), and opioid-naïve groups. Preoperative and postoperative (24 months) outcomes scores were compared within and between groups using the paired t-test and ANCOVA, respectively.Patients were categorized as follows: 226 strong, 762 weak, and 16 opioid naïve. The strong and weak groups were similar with respect to age, sex, race, marital status, education level, Worker's Compensation status, litigation status, and alcohol use. At 24-month follow-up, no differences in change in arm or neck pain scores (arm: strong -52.3, weak -50.6, naïve -54.0, p = 0.244; neck: strong -52.7, weak -50.8, naïve -44.6, p = 0.355); NDI scores (strong -36.0, weak -33.3, naïve -32.3, p = 0.181); or SF-36 Physical Component Summary scores (strong: 14.1, weak 13.3, naïve 21.7, p = 0.317) were present. Using a 15-point improvement in NDI to determine success, the authors found no between-groups difference in success rates (strong 80.6%, weak 82.7%, naïve 73.3%, p = 0.134). No difference existed between treatment arms (TDA vs ACDF) for any outcome at any time point.Preoperative opioid strength did not adversely affect outcomes in this analysis. Careful patient selection can yield good results in this patient population.

  View details for DOI 10.3171/2015.1.SPINE14985

  View details for PubMedID 26140401

  View details for PubMedCentralID PMC4701382

• Spinal Deformity Associated with Chiari Malformation. Neurosurgery clinics of North America Kelly, M. P., Guillaume, T. J., Lenke, L. G. 2015; 26 (4): 579-85

  Abstract

  Despite the frequency of Chiari-associated spinal deformities, this disease process remains poorly understood. Syringomyelia is often present; however, this is not necessary and scoliosis has been described in the absence of a syrinx. Decompression of the hindbrain is often recommended. In young patients (<10 years old) and/or those with small coronal Cobb measurements (<40°), decompression of the hindbrain may lead to resolution of the spinal deformity. Spinal fusion is reserved for those curves that progress to deformities greater than 50°. Further research is needed to understand the underlying pathophysiology to improve prognostication and treatment of this patient population.

  View details for DOI 10.1016/j.nec.2015.06.005

  View details for PubMedID 26408068

  View details for PubMedCentralID PMC4584090

• Genetic Risk for Aortic Aneurysm in Adolescent Idiopathic Scoliosis. The Journal of bone and joint surgery. American volume Haller, G., Alvarado, D. M., Willing, M. C., Braverman, A. C., Bridwell, K. H., Kelly, M., Lenke, L. G., Luhmann, S. J., Gurnett, C. A., Dobbs, M. B. 2015; 97 (17): 1411-7

  Abstract

  Scoliosis is a feature of several genetic disorders that are also associated with aortic aneurysm, including Marfan syndrome, Loeys-Dietz syndrome, and type-IV Ehlers-Danlos syndrome. Life-threatening complications of aortic aneurysm can be decreased through early diagnosis. Genetic screening for mutations in populations at risk, such as patients with adolescent idiopathic scoliosis, may improve recognition of these disorders.The coding regions of five clinically actionable genes associated with scoliosis (COL3A1, FBN1, TGFBR1, TGFBR2, and SMAD3) and aortic aneurysm were sequenced in 343 adolescent idiopathic scoliosis cases. Gene variants that had minor allele frequencies of <0.0001 or were present in human disease mutation databases were identified. Variants were classified as pathogenic, likely pathogenic, or variants of unknown significance.Pathogenic or likely pathogenic mutations were identified in 0.9% (three) of 343 adolescent idiopathic scoliosis cases. Two patients had pathogenic SMAD3 nonsense mutations consistent with type-III Loeys-Dietz syndrome and one patient had a pathogenic FBN1 mutation with subsequent confirmation of Marfan syndrome. Variants of unknown significance in COL3A1 and FBN1 were identified in 5.0% (seventeen) of 343 adolescent idiopathic scoliosis cases. Six FBN1 variants were previously reported in patients with Marfan syndrome, yet were considered variants of unknown significance based on the level of evidence. Variants of unknown significance occurred most frequently in FBN1 and were associated with greater curve severity, systemic features of Marfan syndrome, and joint hypermobility.Clinically actionable pathogenic mutations in genes associated with adolescent idiopathic scoliosis and aortic aneurysm are rare in patients with adolescent idiopathic scoliosis who are not suspected of having these disorders, although variants of unknown significance are relatively common.Routine genetic screening of all patients with adolescent idiopathic scoliosis for mutations in clinically actionable aortic aneurysm disease genes is not recommended on the basis of the high frequency of variants of unknown significance. Clinical evaluation and family history should heighten indications for genetic referral and testing.

  View details for DOI 10.2106/JBJS.O.00290

  View details for PubMedID 26333736

  View details for PubMedCentralID PMC4551173

• Risks and outcomes of spinal deformity surgery in Chiari malformation, Type 1, with syringomyelia versus adolescent idiopathic scoliosis SPINE JOURNAL Godzik, J., Holekamp, T. F., Limbrick, D. D., Lenke, L. G., Park, T. S., Ray, W. Z., Bridwell, K. H., Kelly, M. P. 2015; 15 (9): 2002-2008

  Abstract

  Chiari malformation, Type 1, with syringomyelia (CIM+SM) is often associated with spinal deformity. The safety of scoliosis surgery this population is controversial and has never been directly compared with adolescent idiopathic scoliosis (AIS).The purpose of this study was to compare the safety and subjective outcomes of spinal deformity surgery between patients with Chiari malformation Type 1-associated scoliosis and a matched AIS cohort.This study is based on a retrospective matched cohort analysis.Patients with CIM+SM and treated with spinal fusion for spinal deformity were identified in the surgical records of a single institution and were matched, 1:1, with AIS patients undergoing spinal fusion at the same institution.The outcome measures were neurological monitoring data quality and integrity, radiographic parameters, and Scoliosis Research Society Questionnaire-22 (SRS-22) scores.A clinical database was reviewed for patients undergoing spinal reconstruction for CIM+SM-associated spinal deformity at our institution from 2000 to 2012. Thirty-six CIM+SM patients were identified and matched to an AIS cohort (1:1) based on age, gender, major curve magnitude, fusion length, and revision status. Demographics, deformity morphology, surgical details, neuromonitoring data, and preoperative and postoperative SRS-22 scores were recorded at a minimum of 2-year follow-up. Changes in SRS-22 scores were compared within and between groups. Complications and neurological monitoring data issues were compared between groups.Mean age was 14.5±5 years (CIM+SM: 14.6±5; AIS: 14.4±5), and 42% of patients were male. Preoperative mean major coronal Cobb measured 58°±25° versus 57°±17° (p=.84) with mean kyphosis 52°±17° versus 41°±20° (p=.018). An average of 10.4±2.6 vertebral levels were fused (10.4±2.8 vs. 10.4±2.3, p=.928). No differences existed in surgical approach (p=.336), estimated blood loss (680±720 vs. 660±310 mL, p=.845), or duration of surgery (6.0±2.2 vs. 5.6±2 hours, p=.434). Complication rate was comparable between the two groups (33% vs. 14%, p=.052). Chiari malformation, Type 1, with syringomyelia experienced more neurological complications (11% vs. 0%, p=.04) and neuromonitoring difficulties (28% vs. 3%, p=.007) than the AIS cohort. Mean curve correction was comparable at 2 years (58% CIM+SM vs. 64% AIS, p=.2). At follow-up, both CIM+SM and AIS groups demonstrated improved cumulative SRS-22 outcome subscores (CIM+SM: +0.4, p=.027; AIS: +0.3, p<.001). No difference in outcome subscores existed between CIM+SM and AIS groups.Although CIM+SM patients undergoing spine reconstruction can expect similar deformity corrections and outcome scores to AIS patients, they also experience higher rates of neuromonitoring difficulties and neurological complications related to surgery. Surgeons should be prepared for these difficulties, particularly in children with larger syrinx size.

  View details for DOI 10.1016/j.spinee.2015.04.048

  View details for Web of Science ID 000360086800012

  View details for PubMedID 25959792

  View details for PubMedCentralID PMC4550545

• Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction. Journal of neurosurgery. Spine Scheer, J. K., Smith, J. S., Clark, A. J., Lafage, V., Kim, H. J., Rolston, J. D., Eastlack, R., Hart, R. A., Protopsaltis, T. S., Kelly, M. P., Kebaish, K., Gupta, M., Klineberg, E., Hostin, R., Shaffrey, C. I., Schwab, F., Ames, C. P. 2015; 22 (5): 540-53

  Abstract

  OBJECT Back and leg pain are the primary outcomes of adult spinal deformity (ASD) and predict patients' seeking of surgical management. The authors sought to characterize changes in back and leg pain after operative or nonoperative management of ASD. Outcomes were assessed according to pain severity, type of surgical procedure, Scoliosis Research Society (SRS)-Schwab spine deformity class, and patient satisfaction. METHODS This study retrospectively reviewed data in a prospective multicenter database of ASD patients. Inclusion criteria were the following: age > 18 years and presence of spinal deformity as defined by a scoliosis Cobb angle ≥ 20°, sagittal vertical axis length ≥ 5 cm, pelvic tilt angle ≥ 25°, or thoracic kyphosis angle ≥ 60°. Patients were grouped into nonoperated and operated subcohorts and by the type of surgical procedure, spine SRS-Schwab deformity class, preoperative pain severity, and patient satisfaction. Numerical rating scale (NRS) scores of back and leg pain, Oswestry Disability Index (ODI) scores, physical component summary (PCS) scores of the 36-Item Short Form Health Survey, minimum clinically important differences (MCIDs), and substantial clinical benefits (SCBs) were assessed. RESULTS Patients in whom ASD had been operatively managed were 6 times more likely to have an improvement in back pain and 3 times more likely to have an improvement in leg pain than patients in whom ASD had been nonoperatively managed. Patients whose ASD had been managed nonoperatively were more likely to have their back or leg pain remain the same or worsen. The incidence of postoperative leg pain was 37.0% at 6 weeks postoperatively and 33.3% at the 2-year follow-up (FU). At the 2-year FU, among patients with any preoperative back or leg pain, 24.3% and 37.8% were free of back and leg pain, respectively, and among patients with severe (NRS scores of 7-10) preoperative back or leg pain, 21.0% and 32.8% were free of back and leg pain, respectively. Decompression resulted in more patients having an improvement in leg pain and their pain scores reaching MCID. Although osteotomies improved back pain, they were associated with a higher incidence of leg pain. Patients whose spine had an SRS-Schwab coronal curve Type N deformity (sagittal malalignment only) were least likely to report improvements in back pain. Patients with a Type L deformity were most likely to report improved back or leg pain and to have reductions in pain severity scores reaching MCID and SCB. Patients with a Type D deformity were least likely to report improved leg pain and were more likely to experience a worsening of leg pain. Preoperative pain severity affected pain improvement over 2 years because patients who had higher preoperative pain severity experienced larger improvements, and their changes in pain severity were more likely to reach MCID/SCB than for those reporting lower preoperative pain. Reductions in back pain contributed to improvements in ODI and PCS scores and to patient satisfaction more than reductions in leg pain did. CONCLUSIONS The authors' results provide a valuable reference for counseling patients preoperatively about what improvements or worsening in back or leg pain they may experience after surgical intervention for ASD.

  View details for DOI 10.3171/2014.10.SPINE14475

  View details for PubMedID 25700238

• Defining hyoplasia of the atlas: a cadaveric study. Spine Kelly, M. P., Oshima, Y., Yeom, J. S., Agarwal, R., Bajwa, N. S., Riew, K. D. 2014; 39 (21): E1243-7

  Abstract

  Cadaveric study.To define congenital hypoplasia of the atlas.Little has been written about hypoplasia of the atlas and it is usually described in the setting of other skeletal dysplasias or syndromes.A total of 543 cervical spine specimens were randomly selected from the Hamann-Todd collection. Sagittal and coronal diameters of the atlas, axis, and C3 (when available), and the dens diameter were measured using digital calipers. Correction for modern size and radiographical magnification was performed. Hypoplasia of the atlas was defined as the lowest 2.5% of measurements. The correlation between inner sagittal diameters at C1 and C3 was calculated.The mean C1 inner sagittal diameter was 30.8 ± 2.4 mm (range, 23.5-38.1 mm). We defined C1 hypoplasia as an inner sagittal diameter value representing the smallest 2.5% of subjects. Because the mean was 30.8 mm, hypoplasia was defined as a diameter of ≤26.1 mm or less. Correcting for size and magnification of radiographs, hypoplasia is defined as an inner sagittal diameter of the atlas of 28.9 mm. Approximately 10% of cases had a dens that occupied more than 40% of the spinal canal at C1, thus not following Steel's Rule of Thirds. There was only a moderate correlation between the spinal canal diameter at C1 and at C3 (r = 0.483, N = 345; P < 0.001).With an inner sagittal diameter of 26 mm or less, one may describe the atlas as hypoplastic. Ten percent of the specimens had an odontoid process that occupied more than 40% of the spinal canal at C1. There was little correlation between the inner sagittal diameter at C1 and the diameter at C3.N/A.

  View details for DOI 10.1097/BRS.0000000000000516

  View details for PubMedID 25029221

  View details for PubMedCentralID PMC4177343

• Complications and outcomes of complex spine reconstructions in poliomyelitis-associated spinal deformities: a single-institution experience. Spine Godzik, J., Lenke, L. G., Holekamp, T., Sides, B., Kelly, M. P. 2014; 39 (15): 1211-6

  Abstract

  Retrospective case series.To share our institutional experience with spinal reconstruction for deformity correction in patients with a history of poliomyelitis.Polio and postpolio syndrome are not uncommonly related to a paralytic spinal deformity. Limited modern data exist regarding outcomes and complications after spinal reconstruction in this population.A clinical database was reviewed for patients undergoing spinal reconstruction for polio-associated spinal deformity at our institution from 1985 to 2012. Relevant demographic, medical, surgical, and postoperative information were collected from medical records and analyzed. Preoperative and last follow-up Scoliosis Research Society-22 Questionnaire scores were recorded.A total of 22 patients with polio who underwent surgical deformity correction were identified. Mean age was 49 years (range, 12-74 yr), and 15 patients (68%) were female. Preoperative motor deficit was present in 14 of 22 (64%) patients. All patients underwent instrumented spinal fusion (mean, 13 vertebral levels, range, 3-18). Ten (10/22, 45%) patients developed major complications, and 4 patients (4/22, 18%) developed new postoperative neurological deficits. Neurological monitoring yielded a 13% false-negative rate. At 2-year follow-up, 20 of 22 patients maintained an average coronal correction of 25° (33%, P = 0.001) and sagittal correction of 25° (34%, P = 0.003). Minimum 2-year follow-up data were available for 11 of 22 (50%) patients. At an average of 72 months of follow-up (range, 28-134 mo), the mean Scoliosis Research Society-22 Questionnaire pain subscore improved from a mean of 2.75 to 3.6 (P = 0.012); self-image from 2.8 to 3.7 (P = 0.041); function from 3.1 to 3.8 (P = 0.036); satisfaction from 2.1 to 3.9 (P = 0.08); and mental health from 3.7 to 4.5 (P = 0.115).Spine reconstruction for poliomyelitis-associated deformity was associated with high complication rates (54%) and sometimes unreliable neurological monitoring data. Despite this, patients undergoing spine reconstructions had significantly improved outcome scores. These data may help surgeons to appropriately counsel this complicated patient population.

  View details for DOI 10.1097/BRS.0000000000000375

  View details for PubMedID 24825153

  View details for PubMedCentralID PMC4149855

• Sagittal alignment as a predictor of clinical adjacent segment pathology requiring surgery after anterior cervical arthrodesis. The spine journal : official journal of the North American Spine Society Park, M. S., Kelly, M. P., Lee, D. H., Min, W. K., Rahman, R. K., Riew, K. D. 2014; 14 (7): 1228-34

  Abstract

  Postoperative malalignment of the cervical spine may alter cervical spine mechanics and put patients at risk for clinical adjacent segment pathology requiring surgery.To investigate whether a relationship exists between cervical spine sagittal alignment and clinical adjacent segment pathology requiring surgery (CASP-S) following anterior cervical fusion (ACF).Retrospective matched study.A total of 122 patients undergoing ACF between 1996 and 2008 were identified, with a minimum of 2 years of follow-up.Radiographs were reviewed to measure the sagittal alignment using C2 and C7 sagittal plumb lines, distance from the fusion mass plumb line to the C2 and C7 plumb lines, the alignment of the fusion mass, caudally adjacent disc angle, the sagittal slope angle of the superior end plate of the vertebra caudally adjacent to the fusion mass, T1 sagittal angle, overall cervical sagittal alignment, and curve patterns by Katsuura classification.A total of 122 patients undergoing ACF between 1996 and 2008 were identified, with a minimum of 1 year of follow-up. Patients were divided into groups according to the development of CASP (control/CASP-S) and by number/location of levels fused. Radiographs were reviewed to measure the sagittal alignment using C2 and C7 sagittal plumb lines, distance from the fusion mass plumb line to the C2 and C7 plumb lines, the alignment of the fusion mass, caudally adjacent disc angle, the sagittal slope angle of the superior end plate of the vertebra caudally adjacent to the fusion mass, T1 sagittal angle, overall cervical sagittal alignment, and curve patterns by Katsuura classification. Appropriate statistical tests were performed to calculate relationships between the variables and the development of CASP-S. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.The groups were similar with regard to demographic and surgical variables. Lordosis was preserved in 82% (50/61) of the control group but in only 66% (40/61) of the CASP-S group (p=.033). More patients with a straight curve pattern developed CASP-S. The distance from the C2 to the C7 plumb line and T1 sagittal slope angle were lower in the CASP-S group with C5-C6 fusions compared with the control group. Also, the distance from C5-C6 fusion mass to C7 plumb line and C7 sagittal slope angle were lower in the CASP-S group with C5-C6 fusions.Our results suggest that malalignment of the cervical spine following an ACF at C5-C6 has an effect on the development of clinical adjacent segment pathology requiring surgery.

  View details for DOI 10.1016/j.spinee.2013.09.043

  View details for PubMedID 24361126

  View details for PubMedCentralID PMC4019713

• Multiple lower-extremity and pelvic fractures increase pulmonary embolus risk. Orthopedics Godzik, J., McAndrew, C. M., Morshed, S., Kandemir, U., Kelly, M. P. 2014; 37 (6): e517-24

  Abstract

  The incidence of venous thromboembolism after major trauma has been estimated to be as high as 60%, despite appropriate prophylaxis. Pulmonary embolism is associated with deep venous thrombosis and also with significant rates of morbidity and mortality. This study examined risk factors for pulmonary embolism among patients with pelvic and lower-extremity fractures in the National Trauma Data Bank. Univariate analysis and multiple logistic regression were used to assess potential risk factors for pulmonary embolism during the index hospitalization period. A total of 199,952 patients with pelvic and lower-extremity fracture were identified. Of these patients, 918 (0.46%) had a pulmonary embolism and 117 (12%) of them died during hospitalization. The risk of pulmonary embolism was significantly increased in patients with multiple fractures (odds ratio, 1.89; P<.001) only. No significant relationship was found with fracture location (pelvis, femur, tibia). Other factors that were associated with increased rates of pulmonary embolism were obesity (body mass index >40 odds ratio, 3.38; P<.001), history of warfarin use (P=.009), hospital disposition (surgery odds ratio, 1.68; P<.001; intensive care unit odds ratio, 2.4; P<.001), and hospital setting (university odds ratio, 1.36; P<.001). Multiple pelvic or lower-extremity fractures, but not their anatomic locations, were associated with pulmonary embolism in the National Trauma Data Bank. As expected, obese patients and those with a history of warfarin therapy have higher rates of pulmonary embolism. This study offers guidance in identifying patients with musculoskeletal trauma who are at elevated risk for pulmonary embolism.

  View details for DOI 10.3928/01477447-20140528-50

  View details for PubMedID 24972431

• Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study. Neurosurgical focus Kelly, M. P., Lenke, L. G., Shaffrey, C. I., Ames, C. P., Carreon, L. Y., Lafage, V., Smith, J. S., Shimer, A. L. 2014; 36 (5): E17

  Abstract

  The goal in this study was to evaluate the risk factors for complications, including new neurological deficits, in the largest cohort of patients with adult spinal deformity to date.The Scoli-RISK-1 inclusion criteria were used to identify eligible patients from 5 centers who were treated between June 1, 2009, and June 1, 2011. Records were reviewed for patient demographic information, surgical data, and reports of perioperative complications. Neurological deficits were recorded as preexisting or as new deficits. Patients who underwent 3-column osteotomies (3COs) were compared with those who did not (posterior spinal fusion [PSF]). Between-group comparisons were performed using independent samples t-tests and chi-square analyses.Two hundred seven patients were identified-75 who underwent PSF and 132 treated with 3CO. In the latter group, patients were older (58.9 vs 49.4 years, p < 0.001), had a higher body mass index (29.0 vs 25.8, p = 0.029), smaller preoperative coronal Cobb measurements (33.8° vs 56.4°, p < 0.001), more preoperative sagittal malalignment (11.7 cm vs 5.4 cm, p < 0.001), and similar sagittal Cobb measurements (45.8° vs 57.7°, p = 0.113). Operating times were similar (393 vs 423 minutes, p = 0.130), although patients in the 3CO group sustained higher estimated blood loss (2120 vs 1700 ml, p = 0.066). Rates of new neurological deficits were similar (PSF: 6.7% vs 3CO: 9.9%, p = 0.389), and rates of any perioperative medical complication were similar (PSF: 46.7% vs 3CO: 50.8%, p = 0.571). Patients who underwent vertebral column resection (VCR) were more likely to sustain medical complications than those treated with pedicle subtraction osteotomy (73.7% vs 46.9%, p = 0.031), although new neurological deficits were similar (15.8% vs 8.8%, p = 0.348). Regression analysis did not reveal significant predictors of neurological injury or complication from collected data.Despite higher estimated blood loss, rates of all complications (49.3%) and new neurological deficits (8.7%) did not vary for patients who underwent complex reconstruction, whether or not a 3CO was performed. Patients who underwent VCR sustained more medical complications without an increase in new neurological deficits. Prospective studies of patient factors, provider factors, and refined surgical data are needed to define and optimize risk factors for complication and neurological deficits.

  View details for DOI 10.3171/2014.2.FOCUS1419

  View details for PubMedID 24785482

  View details for PubMedCentralID PMC4185213

• Multilevel Posterior Vertebral Column Resection for the Revision of Congenital Dislocation of the Spine Following In Situ Fusion: A Case Report. Spine deformity Stoker, G. E., Lenke, L. G., Kelly, M. P. 2014; 2 (3): 233-238

  Abstract

  Congenital dislocation of the spine (CDS) is a rare condition. Invariably, sagittal or coronal vertebral translation and an angulated neural canal exist. Mechanical instability, encroachment on the canal by the involved vertebrae, and coexistent spinal cord malformations have all been implicated in CDS-related neurologic deficit. Single-level vertebrectomy through a posterior midline approach has been recently described as first-line surgical intervention for CDS.To illustrate the use of multilevel posterior vertebral column resection (pVCR) for the postsurgical revision of CDS-centered spinal deformity.Case report.Review of 2 cases in which CDS was reconstructed with pVCR.A 6-year-old boy developed a 104° cervicothoracic kyphosis and myelopathy. An 11-year-old boy male developed a 92° thoracolumbar deformity but experienced only back pain. Both patients had undergone previous in situ fusion for CDS, and both presented with progressive, rigid, angular kyphosis. Two-level pVCRs were performed. At ultimate follow-up, imaging revealed sagittal correction of 75° (72%) in the 6-year-old child and 64° (70%) in the 11-year-old, and both were neurologically intact.Multilevel pVCR is a technically demanding but feasible option for the treatment of CDS that has proven recalcitrant to in situ fusion.

  View details for DOI 10.1016/j.jspd.2014.02.004

  View details for PubMedID 27927424

• Relationship of syrinx size and tonsillar descent to spinal deformity in Chiari malformation Type I with associated syringomyelia. Journal of neurosurgery. Pediatrics Godzik, J., Kelly, M. P., Radmanesh, A., Kim, D., Holekamp, T. F., Smyth, M. D., Lenke, L. G., Shimony, J. S., Park, T. S., Leonard, J., Limbrick, D. D. 2014; 13 (4): 368-74

  Abstract

  Chiari malformation Type I (CM-I) is a developmental abnormality often associated with a spinal syrinx. Patients with syringomyelia are known to have an increased risk of scoliosis, yet the influence of specific radiographically demonstrated features on the prevalence of scoliosis remains unclear. The primary objective of the present study was to investigate the relationship of maximum syrinx diameter and tonsillar descent to the presence of scoliosis in patients with CM-I-associated syringomyelia. A secondary objective was to explore the role of craniovertebral junction (CVJ) characteristics as additional risk factors for scoliosis.The authors conducted a retrospective review of pediatric patients evaluated for CM-I with syringomyelia at a single institution in the period from 2000 to 2012. Syrinx morphology and CVJ parameters were evaluated with MRI, whereas the presence of scoliosis was determined using standard radiographic criteria. Multiple logistic regression was used to analyze radiological features that were independently associated with scoliosis.Ninety-two patients with CM-I and syringomyelia were identified. The mean age was 10.5 ± 5 years. Thirty-five (38%) of 92 patients had spine deformity; 23 (66%) of these 35 patients were referred primarily for deformity, and 12 (34%) were diagnosed with deformity during workup for other symptoms. Multiple regression analysis revealed maximum syrinx diameter > 6 mm (OR 12.1, 95% CI 3.63-40.57, p < 0.001) and moderate (5-12 mm) rather than severe (> 12 mm) tonsillar herniation (OR 7.64, 95% CI 2.3-25.31, p = 0.001) as significant predictors of spine deformity when controlling for age, sex, and syrinx location.The current study further elucidates the association between CM-I and spinal deformity by defining specific radiographic characteristics associated with the presence of scoliosis. Specifically, patients presenting with larger maximum syrinx diameters (> 6 mm) have an increased risk of scoliosis.

  View details for DOI 10.3171/2014.1.PEDS13105

  View details for PubMedID 24527859

  View details for PubMedCentralID PMC4141637

• Intrawound vancomycin powder eradicates surgical wound contamination: an in vivo rabbit study. The Journal of bone and joint surgery. American volume Zebala, L. P., Chuntarapas, T., Kelly, M. P., Talcott, M., Greco, S., Riew, K. D. 2014; 96 (1): 46-51

  Abstract

  Surgical site infection remains a complication of spine surgery despite routine use of prophylactic antibiotics. Retrospective clinical studies of intrawound vancomycin use have documented a decreased prevalence of surgical site infection after spine surgery. The purpose of the present study was to assess the efficacy of intrawound vancomycin powder in terms of eradicating a known bacterial surgical site contamination in a rabbit spine surgery model.Twenty New Zealand White rabbits underwent lumbar partial laminectomy and wire implantation. The surgical sites were inoculated, prior to closure, by injecting 100 μL of cefazolin-sensitive and vancomycin-sensitive Staphylococcus aureus (S. aureus) (1 × 10⁸ colony-forming units [CFU]/mL) into the wound. Preoperative cefazolin was administered to all rabbits, and vancomycin powder (100 mg) was placed into the wound of ten rabbits prior to closure. The rabbits were killed on postoperative day four, and tissue and wire samples were obtained for bacteriologic assessment. An independent samples t test was used to assess mean group differences, and a Fisher exact test was used to assess differences in categorical variables.The vancomycin-treated and the control rabbits were similar in weight (mean [and standard deviation], 4.1 ± 0.5 kg and 4.0 ± 0.4 kg, respectively; p = 0.60) and sex distribution and had similar durations of surgery (21.7 ± 7.7 minutes and 16.9 ± 6.7 minutes; p = 0.15). The bacterial cultures of the surgical site tissues were negative for all ten vancomycin-treated rabbits and positive for all ten control rabbits (p < 0.0001). Bacterial growth occurred in thirty-nine of forty samples from the control group but in zero of forty samples from the vancomycin group (p < 0.0001). All blood and liver samples were sterile. No rabbit had evidence of sepsis or vancomycin toxicity. Gross examination of the surgical sites showed no differences between the groups.In a rabbit spine-infection model, intrawound vancomycin powder in combination with preoperative cefazolin eliminated S. aureus surgical site contamination. All rabbits that were managed with only prophylactic cefazolin had persistent S. aureus contamination.This animal study supports the findings in prior clinical reports that intrawound vancomycin powder helps reduce the risk of surgical site infections.

  View details for DOI 10.2106/JBJS.L.01257

  View details for PubMedID 24382724

• Pseudarthrosis/Infection/Rate of Revision Kelly , M., Berven , S. Lenke LG, Cheung K (eds.). AOSpine Master Series. 2014
• Posterior Cervical Microdiscectomy/Foraminotomy Kelly , M., Riew , K. Zdeblick TA, Albert TJ (eds). Master Techniques in Orthopaedic Surgery, The Spine, 3rd Edition. 2014 109-117
• Single-level degenerative cervical disc disease and driving disability: results from a prospective, randomized trial. Global spine journal Kelly, M. P., Mitchell, M. D., Hacker, R. J., Riew, K. D., Sasso, R. C. 2013; 3 (4): 237-42

  Abstract

  Study Design Post hoc analysis of prospective, randomized trial. Objective To investigate the disability associated with driving and single-level degenerative, cervical disc disease and to investigate the effect of surgery on driving disability. Methods Post hoc analysis of data obtained from three sites participating in a multicenter, randomized, controlled trial comparing cervical disc arthroplasty (TDA) with anterior cervical discectomy and fusion (ACDF). The driving subscale of the Neck Disability Index (NDI) was analyzed for all patients. A dichotomous severity score was created from the NDI. Statistical comparisons were made within and between groups. Results Two-year follow-up was available for 118/135 (87%) patients. One half of the study population (49.6%) reported moderate or severe preoperative driving difficulty. This disability associated with driving was similar among the two groups (ACDF: 2.5 ± 1.1, TDA: 2.6 ± 1.0, p = 0.646). The majority of patients showed improvement, with no or little driving disability, at the sixth postoperative week (ACDF: 75%, TDA: 90%, p = 0.073). At no follow-up point did a difference exist between groups according to the severity index. Conclusions Many patients suffering from radiculopathy or myelopathy from cervical disc disease are limited in their ability to operate an automobile. Following anterior cervical spine surgery, most patients are able to return to comfortable driving at 6 weeks.

  View details for DOI 10.1055/s-0033-1354250

  View details for PubMedID 24436875

  View details for PubMedCentralID PMC3854580

• Dropped Head Syndrome After Multilevel Cervical Radiofrequency Ablation <i>A Case Report</i> JOURNAL OF SPINAL DISORDERS & TECHNIQUES Stoker, G. E., Buchowski, J. M., Kelly, M. P. 2013; 26 (8): 444-448

  Abstract

  Case report.To describe a serious complication of multilevel radiofrequency ablation (RFA) of the cervical spine.Percutaneous RFA is an accepted nonoperative modality for the treatment of neck pain. When the procedure is performed according to established guidelines, serious adverse events are rare.The authors performed a clinical and radiographic case review.A 54-year-old woman presented with neck pain and weakness with cervical kyphosis. She had undergone left-sided RFA of the third occipital nerve and C2-C4 facet joints 8 weeks prior to presentation. The patient was incapable of extending her neck, although the deformity was passively correctable. Imaging revealed no lesions to which the kyphosis could be attributed. As the deformity progressed over the subsequent 3 months, surgery was recommended. An instrumented posterior fusion from C2 to T2 was performed with correction of the chin-on-chest deformity and improvement in the patient's axial neck pain.Dropped head syndrome is a rare yet potentially debilitating complication of multilevel cervical RFA.

  View details for DOI 10.1097/BSD.0b013e31825c36c0

  View details for Web of Science ID 000327784800010

  View details for PubMedID 22576719

• Fate of the Adult Revision Spinal Deformity Patient <i>A Single Institution Experience</i> SPINE Kelly, M. P., Lenke, L. G., Bridwell, K. H., Agarwal, R., Godzik, J., Koester, L. 2013; 38 (19): E1196-E1200

  Abstract

  Retrospective case series.The aim of this study was to determine the revision rates for all revision spinal deformity (SD) surgical procedures performed at a single center and to investigate the changes in measures of HRQL in these patients.Reported revision rates for primary adult spinal fusion surgical procedures have been in the range of 9% to 45%, but to our knowledge, the revision rate after revision SD surgery has not been reported. The reported improvements in health-related quality of life measures after revision SD surgery have also been quite modest.Four hundred fifty-five consecutive adult revision SD surgical procedures (1995-2008) were identified and the records were reviewed to determine the reason for and timing to any additional operation(s). Scoliosis Research Society (SRS) Outcome scores were recorded at the first visit and at planned follow-up visits.Ninety-four of 455 patients underwent further surgical procedures for a revision rate of 21%. Two-year follow-up was available for 74 (78%) of these patients (mean follow-up, 6.0 yr; range, 2.4-12.6; sex: F = 61, M = 13; mean age, 53 yr; range, 21-78). The most common causes of revision surgery were pseudarthrosis (N = 23, 31%), implant prominence/pain (N = 15, 20%), adjacent segment disease (N = 14, 19%), and infection (N = 10, 14%). Twenty-five (27%) patients underwent more than one revision procedure. SRS outcome scores were available for 50 (68%) patients, at an average follow-up of 4.9 years (range, 2-11.4). The mean improvements in the SRS outcome measures were as follows: pain, 0.74 (P < 0.001); self-image, 0.8 (P < 0.001); function, 0.5 (P < 0.001); satisfaction, 1.2 (P < 0.001); and mental health, 0.3 (P = 0.012).The rate of revision after revision SD surgery was 21%, most commonly due to pseudarthrosis, adjacent segment disease, infection, and implant prominence/pain. However, significant improvements in SRS outcome scores were still observed in those patients requiring additional revision procedures.

  View details for DOI 10.1097/BRS.0b013e31829e764b

  View details for Web of Science ID 000330366800003

  View details for PubMedID 23759813

  View details for PubMedCentralID PMC4016979

• A Cost-Utility Analysis Comparing the Cost-Effectiveness of Simultaneous and Staged Bilateral Total Knee Arthroplasty JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Odum, S. M., Troyer, J. L., Kelly, M. P., Dedini, R. D., Bozic, K. J. 2013; 95A (16): 1441-1449

  Abstract

  The safety and efficacy of simultaneous or staged bilateral total knee arthroplasty have long been debated among orthopaedic surgeons. Advocates for simultaneous bilateral total knee arthroplasty posit that the benefits of decreased costs and recovery time, with no difference in functional outcomes, outweigh the economic costs of potential complications. The purpose of the study was to conduct a cost-utility analysis comparing simultaneous bilateral total knee arthroplasty with staged bilateral total knee arthroplasty.A Markov model was designed to compare the cost-effectiveness of simultaneous bilateral total knee arthroplasty with that of staged bilateral total knee arthroplasty. Nationwide Inpatient Sample data sets from 2004 to 2007 were used to identify 24,574 simultaneous and 382,496 unilateral procedures. On the basis of the codes of the International Classification of Diseases, Ninth Revision, Clinical Modification, perioperative complications were categorized as minor, major, and mortality, and respective probability values were calculated. Nationwide Inpatient Sample data were used to determine hospital costs conditional on procedure type and complications. Rehabilitation costs, anesthesia costs, and heath utilities were estimated from the literature. To minimize selection bias, propensity score matching was used to match the groups on comorbid conditions, socioeconomic variables, and hospital characteristics.Using the matched sample, all complication rates were higher for the staged group. The estimated mean cost (in 2012 U.S. dollars) was $43,401 for simultaneous bilateral total knee arthroplasty compared with $72,233 for staged bilateral total knee arthroplasty. The quality-adjusted life years gained were 9.31 for simultaneous bilateral total knee arthroplasty and 9.29 for staged bilateral total knee arthroplasty. On the basis of these matched results, simultaneous bilateral total knee arthroplasty dominated staged bilateral total knee arthroplasty with lower costs and better outcomes.On the basis of this analysis, simultaneous bilateral total knee arthroplasty is more cost-effective than staged bilateral total knee arthroplasty, with lower costs and better outcomes for the average patient. These data can inform shared medical decision-making when bilateral total knee arthroplasty is indicated.

  View details for DOI 10.2106/JBJS.L.00373

  View details for Web of Science ID 000323362300001

  View details for PubMedID 23965693

• Traction X-ray under general anesthesia helps to save motion segment in treatment of Lenke type 3C and 6C curves. The spine journal : official journal of the North American Spine Society Hamzaoglu, A., Ozturk, C., Enercan, M., Alanay, A. 2013; 13 (8): 845-52

  Abstract

  In patients with structural lumbar curves, several studies have shown the advantages of stopping fusion at L3 and saving L4. However, fusing the L4 may still be deemed necessary in a significant number of patients with structural lumbar curves (ie, Lenke types 3 and 6) when fusion levels are selected by using traditional flexibility X-ray (TXR) methods such as supine side bends and traction.The aim of this retrospective study was to evaluate the effectiveness of the traction X-ray under general anesthesia (TrUGA) method in saving the L4 in patients with Lenke types 3C and 6C curves.This was a retrospective clinical study.Eighty-nine consecutive patients (77 females and 12 males) with adolescent idiopathic scoliosis Lenke types 3C (46 patients) and 6C (43 patients) curves and who underwent an instrumented posterior spinal fusion by a single surgeon were included. The selection of lower instrumented vertebrae (LIV) was done by using the central sacral vertical line (CSVL). LIV was defined as the uppermost vertebrae of the lumbar curve that was not intersected by CSVL on standing anteroposterior radiograph, but became parallel to the sacrum and was intersected by CSVL at the concave bending or TrUGA. The disc wedging under LIV should be parallel or near parallel and rotation of LIV should be corrected at least one to two (Nash-Moe) grades.Radiological evaluation included preoperative standing AP, lateral and TXR, and intraoperative supine TrUGA, which was taken after the induction of anesthesia and before positioning the patient. LIV was determined by using TXR and TrUGA. Preoperative, postoperative with ≥2 year follow-up curve magnitudes, LIV tilt, and disc wedging below LIV and CSVL to T1 distance were all measured. A satisfactory radiographic outcome was determined to be the result if CSVL was within 2 cm of the center of T1, the LIV tilt angle was less than 10°, and any increase in thoracic and lumbar curve during follow-up was less than 5°. Clinical outcome was analyzed by using follow-up Scoliosis Research Society-22 (SRS-22) questionnaire and by the global outcome scores (GOS) for improvement and deterioration measured with a 15-point scale ranging from -7 (no improvement) to +7 (significant improvement).The average follow-up period was 5.4 (range: 2 to 8) years. Average age at surgery was 15.5 (range: 13 to 19) years. Pedicle screw constructs were used in all patients. LIV was L3 in 85 patients, and L4 in the remaining 4 patients. Using the same selection criteria, L3 was LIV according to both the TXR and TrUGA films in 39 cases (44%) and fusion was stopped at L3. In 46 (52%) cases, TXR determined L4 to be the LIV, whereas in all those patients L3 was the LIV according to TrUGA and fusion was stopped at L3 in all. LIV was L4 according to both methods in four (4%) patients and fusion was stopped at L4. All patients had successful radiographic outcomes according to the criteria of CSVL to be within 2 cm of the center of T1, L3 tilt angle of less than 10°, and L3-L4 disc wedging to be less than 10° at the final follow-up. Average follow-up SRS-22 score was 4.3 (range: 3.3-5) and GOS was 6.1 (range: 3-7). None of the patients required additional surgery for decompensation or adding on, and there was no significant correction loss during follow-up.TrUGA may be an alternative method for selection of fusion levels and may help to save L4 when compared with traditional radiograph methods in surgical treatment of Lenke types 3 and 6 curves.

  View details for DOI 10.1016/j.spinee.2013.03.043

  View details for PubMedID 23685218

• Commentary: X-rays under anesthesia as an adjunct to save motion segments in AIS surgery SPINE JOURNAL Kelly, M. P., Lehman, R. A., Lenke, L. G. 2013; 13 (8): 853-855

  Abstract

  Hamzaoglu A, Ozturk C, Enercan M, Alanay A. Traction X-ray under general anesthesia helps to save motion segment in treatment of Lenke type 3C and 6C curves. Spine J 2013;13:845-52 (in this issue).

  View details for DOI 10.1016/j.spinee.2013.06.002

  View details for Web of Science ID 000323170600016

  View details for PubMedID 23906031

• Risk factors for subtrochanteric and diaphyseal fractures: the study of osteoporotic fractures. The Journal of clinical endocrinology and metabolism Napoli, N., Schwartz, A. V., Palermo, L., Jin, J. J., Wustrack, R., Cauley, J. A., Ensrud, K. E., Kelly, M., Black, D. M. 2013; 98 (2): 659-67

  Abstract

  Patients on long-term bisphosphonate therapy may have an increased incidence of low-energy subtrochanteric and diaphyseal (SD) femoral fractures. However, the incidence and risk factors associated with these fractures have not been well defined.The objective of the study was to determine the incidence of and risk factors for low-energy SD fractures in the Study of Osteoporotic Fractures (SOF).Low-energy SD fractures were identified from a review of radiographic reports obtained between 1986 and 2010 in women in the SOF. Among the SD fractures, pathological, periprosthetic, and traumatic fractures were excluded. We assessed risk factors for SD fractures as well as risk factors for femoral neck (FN) and intertrochanteric (IT) hip fractures using both age-adjusted and multivariate time-dependent proportional hazards models. During this follow-up, only a small minority had ever used bisphosphonates.Forty-five women sustained low-energy subtrochanteric/diaphyseal femoral fractures over a total follow-up of 140 000 person-years. The incidence of SD fracture was 3.2 per 10 000 person-years compared with a total hip fracture incidence of 110 per 10 000 person-years. A total of about 12% of women reported bisphosphonate use at 1 or more visits. In multivariate analyses, age, total hip bone mineral density (BMD), bisphosphonate use, and history of diabetes emerged as independent risk factors for SD fractures. Risk factors for FN and IT fractures included age, BMD, and history of falls or prior fractures. Bisphosphonate use was protective against FN fractures, whereas there was an increased risk of SD fractures (hazard ratio 2.58, P = .049) with bisphosphonate use after adjustment for other risk factors for fracture.In SOF, low-energy SD fractures were rare occurrences, far outnumbered by FN and IT fractures. Typical risk factors were associated with FN and IT fractures, whereas only age, total hip BMD, and history of diabetes were independent risk factors for SD fractures. In addition, bisphosphonate use was a marginally significantly predictor although the SOF study has limited ability to assess this association.

  View details for DOI 10.1210/jc.2012-1896

  View details for PubMedID 23345099

  View details for PubMedCentralID PMC3565107

• Surgical Treatment of C3 and C4 Cervical Radiculopathies SPINE Park, M., Kelly, M. P., Min, W., Rahman, R. K., Riew, K. 2013; 38 (2): 112-118

  Abstract

  Case series study.To report the results of surgical intervention in a series of patients with high cervical radiculopathy.Although midcervical (C5-C7) radiculopathy is common and well recognized, high cervical (C3 and C4) radiculopathy is relatively rare and can be missed clinically. To our knowledge, there are few reports regarding the operative treatment of high cervical radiculopathy.Two spine surgeons independently reviewed the charts and radiographs of all patients with high cervical radiculopathy or myeloradiculopathy that were surgically treated by the senior author. Dates of inclusion were from July 1997 to March 2008. All patients were observed for either a minimum of 2 years or until they achieved a fusion. Neck Disability Index scores were calculated pre- and postoperatively, when available, and Odom criteria were assessed for all patients.Twenty-three patients met the inclusion criteria. The mean follow-up period was 4.2 years (1-11.3 yr). The levels involved were C2-C3 (2 patients), C2-C4 (4 patients), and C3-C4 (17 patients). The most common symptom was suboccipital neck pain/headache with or without radiation to the retroauricular or retro-orbital region (21 patients). Preoperative neuroradiological findings were central stenosis with herniated nucleus pulposus, foraminal stenosis with uncinate hypertrophy or facet arthrosis, spondylolisthesis, and pseudarthrosis. Operative treatments included anterior cervical discectomy and fusion, posterior foraminotomy, posterior laminectomy-foraminotomy with fusion, posterior laminoplasty with fusion, and anterior/posterior combined decompression and fusion. By Odom criteria, 12 had excellent results, 8 had good results, 2 had satisfactory results, and 1 had a poor result. One patient underwent a reoperation for pseudarthrosis.Surgical treatment of high cervical radiculopathies resulted in acceptable outcomes. To our knowledge, this is the largest series of this relatively rare condition.

  View details for DOI 10.1097/BRS.0b013e318267b0e6

  View details for Web of Science ID 000313550900013

  View details for PubMedID 22781005

• Vertebral Column Resection for Severe Rigid Spinal Deformity through an All Posterior Approach Kelly , M., Zebala , L., Lenke , L. Wiesel S, Rhee JM (eds) Operative Techniques in Spinal Surgery. 2013 245-59
• Video-assisted thoracoscopic surgery with posterior spinal reconstruction for the resection of upper lobe lung tumors involving the spine SPINE JOURNAL Stoker, G. E., Buchowski, J. M., Kelly, M. P., Meyers, B. F., Patterson, G. 2013; 13 (1): 68-76

  Abstract

  Video-assisted thoracoscopic surgery (VATS) is associated with less morbidity and recovery time compared with traditional open thoracotomy (OT) for the resection of early stage non-small cell lung cancer (NSCLC). Local invasion of NSCLC into adjacent vertebrae confers a TNM T status of T4. Anatomical lobectomy by VATS with simultaneous posterior spinal reconstruction (PSR), as a single procedure, offers advantages to selected patients judged as suitable candidates for resection.To report the preliminary results of a novel, multidisciplinary surgical technique for the treatment of upper lobe lung cancers with direct extension to the spine.Consecutive case series.Eight adults who underwent PSR with either VATS or OT for the treatment of a T4 (vertebral body invasion) NSCLC.Total operative time, estimated blood loss, length of hospital stay, postoperative tumor recurrence and metastasis, survival, reoperations, and any other intraoperative or postoperative complication.Eight consecutive patients who underwent instrumented PSR with corpectomy for the treatment of an upper lobe NSCLC at a single institution were identified. Either VATS (n=4) or OT (n=4) was performed at the time of the reconstruction in each patient. All tumors were stage III NSCLC without metastasis.Patients who underwent VATS and OT were aged 54±11 and 54±2.9 years, respectively. Mean operative time and blood loss were similar between the groups: VATS: 367±117 minutes versus OT: 518±264 minutes; VATS: 813±463 mL versus OT: 1,250±1,500 mL. Mean follow-up was 16±13 months after surgery. Complications occurred in all eight patients. One OT patient had wound dehiscence requiring a tissue flap, and another suffered from a septic shock. No wound complications developed after VATS. Death secondary to tumor recurrence occurred once in each group. For the six surviving patients, 23±15 months (range, 4.5-43 months) have elapsed since surgery.Video-assisted thoracoscopic surgery with PSR is a novel and viable method for the complete resection of T4 NSCLC.

  View details for DOI 10.1016/j.spinee.2012.11.026

  View details for Web of Science ID 000314684300011

  View details for PubMedID 23295033

• Surgical Treatment of Adolescent Idiopathic Scoliosis: Lenke Curve Types 1-6 Lenke , L., Kelly , M. Kim DH, Vaccaro AR, Dickman CA (eds) Surgical Anatomy and Techniques to the Spine, 2nd Edition. 2013 587-600
• Cervical Osteotomies for Kyphosis Kelly , M., Wollowick , A., Riew , K. Wiesel S, Rhee JM (eds) Operative Techniques in Spinal Surgery. 2013 66-74
• The Risk of Adjacent-Level Ossification Development After Surgery in the Cervical Spine <i>Are There Factors That Affect the Risk</i>? <i>A Systematic Review</i> SPINE Kim, H., Kelly, M. P., Ely, C. G., Riew, K., Dettori, J. R. 2012; 37 (22): S65-S74

  Abstract

  Systematic review.To answer the following clinical questions: (1) What is the risk of adjacent-level ossification development (ALOD) in patients receiving noninstrumented cervical fusion, instrumented cervical fusion with a plate, or cervical total disc arthroplasty?; (2) What are the risk factors for ALOD?; (3) What is the time course for the development of ALOD?; and (4) Does ALOD affect outcomes and rates of reoperation?Anterior cervical plating, total disc arthroplasty, and noninstrumented fusion have all been used in the treatment of cervical disc disease. There are numerous reports that identify ALOD, a form of heterotopic ossification, as a major risk factor after performing these procedures. Few studies have compared these 3 procedures to evaluate the risk, timing, and outcomes related to postoperation ALOD.A systematic search was conducted in PubMed and the Cochrane Library for articles published between January 1, 1990, and December 31, 2011. We included all articles that described the risk of or risk factors for ALOD after surgical treatment of the cervical spine. Studies with patients older than 18 years or those treated for tumor or trauma were excluded from the study. In addition, those with posterior fusions, case reports, and case series with less than 10 patients were excluded.A total of 5 studies met the inclusion criteria for our systematic review. The risk of ALOD with anterior cervical discectomy and fusion ranged from 41% to 64%, whereas the risk of ALOD after total disc replacement ranged from 6% to 24%. When ALOD did occur, there was a 2-fold higher risk of development at the cranial adjacent segment. The most important risk factor for the development of ALOD was the use of instrumentation and the plate-to-disc distance, although the surgical procedure type (corpectomy vs. discectomy and fusion) neared but did not reach statistical significance. Insufficient evidence was available to delineate the time course for its development and how ALOD affected outcomes.The current body of literature suggests that ALOD will develop with the use of instrumentation and especially so if anterior instrumentation is placed within 5 mm of the adjacent cranial disc segment. In addition, total disc replacement showed lower rates for the development of ALOD compared with anterior cervical discectomy and fusion at both short- and long-term follow-up.We recommend that the surgeon make every effort to keep the plate as far away from the adjacent disc as possible. Strength of Statement: Strong.

  View details for DOI 10.1097/BRS.0b013e31826cb8f5

  View details for Web of Science ID 000310434900008

  View details for PubMedID 22872223

• Terminology INTRODUCTION SPINE Anderson, P. A., Andersson, G. B. J., Arnold, P. M., Brodke, D. S., Brodt, E. D., Chapman, J. R., Chou, D., Dekutoski, M., Dettori, J. R., DeVine, J. G., Ely, C. G., Fehlings, M. G., Fischer, D. J., Fourney, D. R., Hansen, M. A., Harrod, C., Hashimoto, R., Hermsmeyer, J. T., Hilibrand, A. S., Kasliwal, M. K., Kelly, M. P., Kim, H., Kraemer, P., Lawrence, B. D., Lee, M. J., Lenke, L. G., Norvell, D. C., Raich, A., Riew, K., Shaffrey, C. I., Skelly, A. C., Smith, J. S., Standaert, C. J., Van Alstyne, E. M., Wang, J. C. 2012; 37 (22): S8-S9

  View details for DOI 10.1097/BRS.0b013e31826d62ed

  View details for Web of Science ID 000310434900002

  View details for PubMedID 22878707

• Are women with thicker cortices in the femoral shaft at higher risk of subtrochanteric/diaphyseal fractures? The study of osteoporotic fractures. The Journal of clinical endocrinology and metabolism Napoli, N., Jin, J., Peters, K., Wustrack, R., Burch, S., Chau, A., Cauley, J., Ensrud, K., Kelly, M., Black, D. M. 2012; 97 (7): 2414-22

  Abstract

  Femoral shaft cortical thickening has been mentioned in reports of atypical subtrochanteric and diaphyseal (S/D) femur fractures, but it is unclear whether thickening precedes fracture or results from a preceding stress fracture and what role bisphosphonates might play in cortical thickening.Our objective was to examine the relationship of cortical thickness to S/D fracture risk as well as establish normal reference values for femoral cortical thickness in a large population-based cohort of older women.Using pelvic radiographs obtained in 1986-1988, we measured femoral shaft cortical thickness 3 cm below the lesser trochanter in women in the Study of Osteoporotic Fractures. We measured this in a random sample and in those with S/D fractures and femoral neck and intertrochanteric fractures. Low-energy S/D fractures were identified from review of radiographic reports obtained between 1986 and 2010. Radiographs to evaluate atypia were not available. Analysis used case-cohort, proportional hazards models.Cortical thickness as a risk factor for low-energy S/D femur fractures as well as femoral neck and intertrochanteric fractures in the Study of Osteoporotic Fractures, adjusting for age and bone mineral density in proportional hazards models.After age adjustment, women with thinner medial cortices were at a higher risk of S/D femur fracture, with a relative hazard of 3.94 (95% confidence interval = 1.23-12.6) in the lowest vs. highest quartile. Similar hazard ratios were seen for femoral neck and intertrochanteric fractures. Medial or total cortical thickness was more strongly related to fracture risk than lateral cortical thickness.In primarily bisphosphonate-naive women, we found no evidence that thick femoral cortices placed women at higher risk for low-energy S/D femur fractures; in fact, the opposite was true. Women with thin cortices were also at a higher risk for femoral neck and intertrochanteric fractures. Whether cortical thickness among bisphosphonate users plays a role in atypical S/D fractures remains to be determined.

  View details for DOI 10.1210/jc.2011-3256

  View details for PubMedID 22547423

  View details for PubMedCentralID PMC3387394

• Pedicle Subtraction Osteotomy in the Cervical Spine SPINE Wollowick, A. L., Kelly, M. P., Riew, K. 2012; 37 (5): E342-E348

  Abstract

  Description of surgical technique with review of literature.To describe the surgical management of cervical spine deformity, using pedicle subtraction osteotomy.Previous articles have primarily described Smith-Petersen osteotomies and Simmons' modifications to correct fixed cervical deformity. Those were typically performed with the patient awake and sedated in a seated position and without the use of spinal instrumentation.Description of a single surgeon's technique for performing pedicle subtraction osteotomy to treat fixed cervical deformity.The use of pedicle subtraction osteotomy in the cervical spine is a safe and effective procedure when performed by experienced surgeons and can result in a satisfying outcome for both the patient and the surgeon.

  View details for DOI 10.1097/BRS.0b013e318245bcd4

  View details for Web of Science ID 000300872300012

  View details for PubMedID 22366945

• Osteotomy techniques (Smith-Petersen and pedicle subtraction) for fixed sagittal imbalance Zebala , L., Kelly , M., Bridwell , K. Vaccaro AR, Baron EM (eds) Operative Techniques: Spine Surgery, 2nd Edition. 2012 270-279
• Adjacent Segment Motion After Anterior Cervical Discectomy and Fusion Versus ProDisc-C Cervical Total Disk Arthroplasty SPINE Kelly, M. P., Mok, J. M., Frisch, R. F., Tay, B. K. 2011; 36 (15): 1171-1179

  Abstract

  Post hoc analysis of data acquired in a prospective, randomized, controlled trial.To compare adjacent segment motion after anterior cervical discectomy and fusion (ACDF) versus cervical total disc arthroplasty (TDA).TDA has been designed to be a motion-preserving device, thus theoretically normalizing adjacent segment kinematics. Clinical studies with short-term follow-up have yet to demonstrate a consistent significant difference in the incidence of adjacent segment disease.Two hundred nine patients at 13 sites were treated in a prospective, randomized, controlled trial of ACDF versus TDA for single-level symptomatic cervical degenerative disc disease (SCDD). Flexion and extension radiographs were obtained at all follow-up visits. Changes in ROM were compared using the Wilcoxon signed-rank test and the Mann-Whitney U test. Predictors of postoperative ROM were determined by multivariate analysis using mixed effects linear regression.Data for 199 patients were available with 24-month follow-up. The groups were similar with respect to baseline demographics. A significant increase in motion at the cranial and caudal adjacent segments after surgery was observed in the ACDF group only (cranial: ACDF: +1.4° (0.4, 2.4), P = 0.01; TDA: +0.8°, (-0.1, +1.7), P = 0.166; caudal: ACDF: +2.6° (1.3, 3.9), P < 0.0001; TDA: +1.3, (-0.2, +2.8), P = 0.359). No significant difference in adjacent segment ROM was observed between ACDF and TDA. Only time was a significant predictor of postoperative ROM at both the cranial and caudal adjacent segments.Adjacent segment kinematics may be altered after ACDF and TDA. Multivariate analysis showed time to be a significant predictor of changes in adjacent segment ROM. No association between the treatment chosen (ACDF vs. TDA) and ROM was observed. Furthermore clinical follow-up is needed to determine whether possible differences in adjacent segment motion affect the prevalence of adjacent segment disease in the two groups.

  View details for DOI 10.1097/BRS.0b013e3181ec5c7d

  View details for Web of Science ID 000291852500012

  View details for PubMedID 21217449

• Bisphosphonates and fractures of the subtrochanteric or diaphyseal femur. The New England journal of medicine Black, D. M., Kelly, M. P., Genant, H. K., Palermo, L., Eastell, R., Bucci-Rechtweg, C., Cauley, J., Leung, P. C., Boonen, S., Santora, A., de Papp, A., Bauer, D. C. 2010; 362 (19): 1761-71

  Abstract

  A number of recent case reports and series have identified a subgroup of atypical fractures of the femoral shaft associated with bisphosphonate use. A population-based study did not support this association. Such a relationship has not been examined in randomized trials.We performed secondary analyses using the results of three large, randomized bisphosphonate trials: the Fracture Intervention Trial (FIT), the FIT Long-Term Extension (FLEX) trial, and the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) Pivotal Fracture Trial (PFT). We reviewed fracture records and radiographs (when available) from all hip and femur fractures to identify those below the lesser trochanter and above the distal metaphyseal flare (subtrochanteric and diaphyseal femur fractures) and to assess atypical features. We calculated the relative hazards for subtrochanteric and diaphyseal fractures for each study.We reviewed 284 records for hip or femur fractures among 14,195 women in these trials. A total of 12 fractures in 10 patients were classified as occurring in the subtrochanteric or diaphyseal femur, a combined rate of 2.3 per 10,000 patient-years. As compared with placebo, the relative hazard was 1.03 (95% confidence interval [CI], 0.06 to 16.46) for alendronate use in the FIT trial, 1.50 (95% CI, 0.25 to 9.00) for zoledronic acid use in the HORIZON-PFT trial, and 1.33 (95% CI, 0.12 to 14.67) for continued alendronate use in the FLEX trial. Although increases in risk were not significant, confidence intervals were wide.The occurrence of fracture of the subtrochanteric or diaphyseal femur was very rare, even among women who had been treated with bisphosphonates for as long as 10 years. There was no significant increase in risk associated with bisphosphonate use, but the study was underpowered for definitive conclusions.

  View details for DOI 10.1056/NEJMoa1001086

  View details for PubMedID 20335571

• Dynamic Constructs for Spinal Fusion: An Evidence-Based Review ORTHOPEDIC CLINICS OF NORTH AMERICA Kelly, M. P., Mok, J. M., Berven, S. 2010; 41 (2): 203-+

  Abstract

  Dynamic stabilization of the spine has applications in cervical and lumbar degenerative disease and in thoracolumbar trauma. There is little evidence to support the use of dynamic cervical plates rather than rigid anterior cervical fixation. Evidence to support the use of dynamic constructs for fusion in the lumbar spine is also limited. Fusion rates, implant loosening, and failure are significant concerns that limit the adoption of current devices. This article provides a synopsis of the literature on human subjects. There is a need for high-quality evidence for interventions for spinal pathology. An evidence-based approach to the management of spinal disorders will require ongoing assessment of clinical outcomes and comparison of effectiveness between alternatives.

  View details for DOI 10.1016/j.ocl.2009.12.004

  View details for Web of Science ID 000277461800009

  View details for PubMedID 20399359

• Nutrition and Pain Management in the Adult Spinal Deformity Patient Kelly , M., Hu , S. Ogilvie JW (ed) Scoliosis Research Society E-Text, Spine Deformity Surgery. www.srs.org. 2010
• Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clinical orthopaedics and related research Kurtz, S. M., Lau, E., Ong, K., Zhao, K., Kelly, M., Bozic, K. J. 2009; 467 (10): 2606-12

  Abstract

  Previous projections of total joint replacement (TJR) volume have not quantified demand for TJR surgery in young patients (< 65 years old). We developed projections for demand of TJR for the young patient population in the United States. The Nationwide Inpatient Sample was used to identify primary and revision TJRs between 1993 and 2006, as a function of age, gender, race, and census region. Surgery prevalence was modeled using Poisson regression, allowing for different rates for each population subgroup over time. If the historical growth trajectory of joint replacement surgeries continues, demand for primary THA and TKA among patients less than 65 years old was projected to exceed 50% of THA and TKA patients of all ages by 2011 and 2016, respectively. Patients less than 65 years old were projected to exceed 50% of the revision TKA patient population by 2011. This study underscores the major contribution that young patients may play in the future demand for primary and revision TJR surgery.Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

  View details for DOI 10.1007/s11999-009-0834-6

  View details for PubMedID 19360453

  View details for PubMedCentralID PMC2745453

• Cost drivers in total hip arthroplasty: effects of procedure volume and implant selling price. American journal of orthopedics (Belle Mead, N.J.) Kelly, M. P., Bozic, K. J. 2009; 38 (1): E1-4

  Abstract

  Total hip arthroplasty (THA), though a highly effective procedure for patients with end-stage hip disease, has become increasingly costly, both because of increasing procedure volume and because of the introduction and widespread use of new technologies. Data regarding procedure volume and procedure costs for THA were obtained from the National Inpatient Sample and other published sources for the years 1995 through 2005. Procedure volume increased 61% over the period studied. When adjusted for inflation, using the medical consumer price index, the average selling price of THA implants increased 24%. The selling price of THA implants as a percentage of total procedure costs increased from 29% to 60% during the period under study. The increasing cost of THA in the United States is a result of both increased procedure volume and increased cost of THA implants. No long-term outcome studies related to use of new implant technologies are available, and short-term results have been similar to those obtained with previous generations of THA implants. This study reinforces the need for a US total joint arthroplasty registry and for careful clinical and economic analyses of new technologies in orthopedics.

  View details for PubMedID 19238268

• Osteoporosis and vitamin-D deficiency among postmenopausal women with osteoarthritis undergoing total hip arthroplasty. The Journal of bone and joint surgery. American volume Glowacki, J., Hurwitz, S., Thornhill, T. S., Kelly, M., LeBoff, M. S. 2003; 85 (12): 2371-7

  Abstract

  Several epidemiological studies have shown a lower prevalence of osteoporotic hip fractures in patients with osteoarthritis. Other studies have demonstrated elevated bone mineral density in patients with osteoarthritis. The prevailing view is that there may be an inverse relationship between osteoarthritis and osteoporosis. The purposes of the present study were to describe a subgroup of patients with osteoarthritis who were found to have osteoporosis and to assess the vitamin-D status and other risk factors for low bone density in osteoarthritic subjects with and without osteoporosis.The bone mineral density of the spine, the proximal part of the femur, and the total body was measured with dual-energy x-ray absorptiometry in sixty-eight postmenopausal white women who were scheduled to undergo total hip replacement for advanced osteoarthritis. The serum levels of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, intact parathyroid hormone, osteocalcin, and bone-specific alkaline phosphatase and the urinary level of N-telopeptide were measured. Information from validated lifestyle, dietary, and demographic questionnaires was also evaluated.Seventeen (25%) of the sixty-eight women had occult osteoporosis (as indicated by a T score of less than -2.5). Fifteen (22%) of the sixty-eight subjects had vitamin-D deficiency, and three (4%) had an elevated serum parathyroid hormone level. Only two of the seventeen osteoporotic women had vitamin-D deficiency. On the basis of these numbers, vitamin-D status was not correlated with bone density (p = 0.32). Analysis of the relationship between the number of years since menopause and osteoporosis or markers of elevated bone turnover showed that osteoporosis was detected throughout the postmenopausal period.A substantial portion of these sixty-eight white women with osteoarthritis of the hip had occult osteoporosis and hypovitaminosis D. Vitamin-D deficiency was not restricted to the group with low bone density. These results support the need to consider the presence of both osteoporosis and vitamin-D deficiency in women with advanced osteoarthritis.

  View details for DOI 10.2106/00004623-200312000-00015

  View details for PubMedID 14668507