Michael Patrick Kelly

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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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