Papers by Bassel G. Diebo
The spine journal : official journal of the North American Spine Society, Jan 4, 2015
Evaluation of sagittal alignment is essential in the operative treatment of spine pathology, part... more Evaluation of sagittal alignment is essential in the operative treatment of spine pathology, particularly adult spinal deformity (ASD). However, software applications for detailed spino-pelvic analysis are usually complex and not applicable to routine clinical use PURPOSE: To validate a new clinician-friendly software (Surgimap) in the setting of ASD. Accuracy and inter- and intra-rater reliability of a spine measurement software. Five users (2 experienced -spine surgeon, 3 novice - spine researched fellow) independently performed each part of the study in two rounds with one week between measurements. 50 ASD patients drawn from a prospective database. Spinal, pelvic, and cervical measurements parameters (including pelvic tilt [PT], pelvic incidence [PI], lumbar-pelvic mismatch [PI-LL], lumbar lordosis [LL], thoracic kyphosis [TK], T1 spino-pelvic inclination [T1SPI], sagittal vertical axis [SVA], cervical lordosis [CL]). For the accuracy evaluation, 30 ASD patient radiographs were ...
Introduction:The musculoskeletal system provides a wide range of compensatory mechanisms to maint... more Introduction:The musculoskeletal system provides a wide range of compensatory mechanisms to maintain sagittal alignment of the whole body. While several of these mechanisms have been described in the setting of sagittal spinopelvic analysis, the distribution of compensation among musculoskeletal components and preferred mechanisms relating to the patient's age are poorly understood. Methods:This is a retrospective review of adult sagittal spinal deformity (SSD) patients who underwent full body stereoradiography between 2012-2013. Radiographic measurements were performed with dedicated software. The driver of spino-pelvic malalignment was defined as the loss of lumbar lordosis (LL) in relation to the fixed pelvic morphology represented by Pelvic Incidence (PI), such that: PI-LL > 10ᵒ. Patients were categorized based on their age (greater or younger than 65 years), and compensatory mechanisms for each group were compared among different magnitudes of spino-pelvic malalignment. Compensatory mechanisms of each component of the musculoskeletal system were used ( : thoracic kyphosis (TK, T4-T12) flattening, pelvic retroversion (PT), pelvic posterior offset in relation to the anterior cortex of the tibia (pelvic shift, [P.Sh]), knee flexion angle (KA), and cervical lordosis (CL, C2-C7). Results:161 Patients were included with a mean age of 62.93+12.8yrs, BMI 27, and 80.6% females. Patients were categorized into two age groups greater or less than 65 years. Group 1 (n = 88), mean age: 54.73 y/o; Group 2 (n = 73), mean age: 72.81 y/o. Spino-pelvic malalignment cutoffs (PI-LL) were 10ᵒ-20ᵒ, ᵒ20-30ᵒ, 30ᵒ-40ᵒ, >40ᵒ. Overall, patients recruited more components to compensate for greater spino-pelvic malalignment. The younger group recruited thoracic hypokyphosis at a deformity of ᵒ20-30ᵒ, whereas the older group saved it until the deformity reached the stage of > 40ᵒ. The younger group recruited pelvic retroversion up to 30.02ᵒ, whereas the older group recruited this mechanism up to 41.72ᵒ and that was significantly different. At the malalignment stage of 30ᵒ-40ᵒ, the younger group recruited P.Sh significantly less than older group, and at this stage P.Sh contributed the most to musculoskeletal compensation. Cervical lordosis was significantly different between the age groups at the malalignment stage of 20ᵒ-30 and 30ᵒ-40ᵒ . Discussion and Conclusion:As sagittal malalignment increases, more compensatory mechanisms are utilized. However, the recruitment of compensatory mechanisms varies among life stages. At a mild level of deformity, younger
Don’t Know Your Patient’s Global Sagittal Angle? You Should Many people look for a new angle when... more Don’t Know Your Patient’s Global Sagittal Angle? You Should Many people look for a new angle when searching for answers. Bassel Diebo, M.D. a spine research fellow in the spine lab at NYU Langone Medical Center, has found one. Dr. Diebo tells OTW, “In my quest to study the impact of spinal alignment on the musculoskeletal system, I was inspired by the work of Jean Dubousset about the ‘conus of economy,’ defined as the cone in which the body can stay balanced within a narrow range (polygon of sustentation) without energy expenditure. When I looked at the EOS imaging of a number of patients I noticed that we were missing an opportunity to capture information on what was happening with the lower body when it comes to spinal malalignment.”
The Spine Journal, 2014
3-Column osteotomy (3CO) is an effective technique to correct sagittal malalignment, but is assoc... more 3-Column osteotomy (3CO) is an effective technique to correct sagittal malalignment, but is associated with high complication rates. Whether the angle of wedge resection and spinal level of the osteotomy are well correlated to the correction of spino-pelvic parameters remains unclear. This study sought to investigate the impact of the osteotomy site on sagittal correction. Post-operative apex of lumbar lordosis has a significant impact on pelvic tilt with more caudal 3CO levels associated with higher post-operative motor deficits and revision.
The Spine Journal, 2014
METHODS: A total of 168 intact L4-L5 spinal segments (87M/81F, 53.1612.1 yrs) were tested using p... more METHODS: A total of 168 intact L4-L5 spinal segments (87M/81F, 53.1612.1 yrs) were tested using pure moment loading (7.5 Nm) simulating flexion-extension, lateral bending and axial rotation. Axial compression tests (to 300N) were performed on 38 of the specimens. Gender, age and BMI (at time of death) were collected from the donor records provided by local tissue banks and were analyzed with biomechanical parameters using one way-ANOVA, Pearson correlation and multiple regression analyses. RESULTS: Considering the entire population (n5168), there were no statistical differences between all male and all female groups in terms of age or BMD. The mean BMI in the female group was significantly greater than in the male group (p50.005). Further subdivision of groups into BMI!30 (52M/30F) and BMIO30 (30M/42F) did not result in any differences in mean age, BMD or BMI between male and female groups in either BMI category (pO0.1). The segments from the obese (BMIO30) male group were significantly more mobile than those from the non-obese (BMI! 30) male group during axial rotation (p50.018), while there was no difference in the female group (p50.687). There were no differences in mobility between spines from obese and non-obese donors during flexion-extension or lateral bending, for either gender. In the non-obese population, the ROM during axial rotation was significantly greater for the female vs. male group (p50.009). There was no significant difference between gender in the obese population (p50.892). Axial compressive stiffness was significantly greater for the obese population for both the female group and the entire study group (p!0.01); however, the difference was non-significant in the male population (p50.304). Correlation analysis confirmed a significant negative correlation between BMI and resistance to deformation during axial compression in the female group (R5-0.65, p50.004), with no relationship in the male group (R50.03, p50.9). There was a significant negative correlation between ROM during flexion-extension and BMI for the female group (R5-0.38, p50.001), with no relationship in the male group (R50.06, p50.58). CONCLUSIONS: The unknown proportion of symptomatic vs asymptomatic donors in each group is a confounding factor. However, based on flexibility and compression tests, lumbar spinal segments from obese vs non-obese donors seem to behave differently, biomechanically, during axial rotation and compression, with coinciding gender differences. The noted gender differences in the biomechanical behavior at L4-L5 may be related to differences in gait patterns, weight distribution and childbearing.
The Spine Journal, 2014
BODY: Summary (80 words max): Spino-pelvic mechanisms of compensation involve modified sagittal s... more BODY: Summary (80 words max): Spino-pelvic mechanisms of compensation involve modified sagittal spinal curvatures, retroversion of the pelvis in addition to knee flexion and pelvic shift. However, lower limb mechanisms of compensation remain poorly described. 161 patients with sagittal spinal deformity (SSD) received full body stereoradiographs and were analyzed for compensatory mechanisms. Preliminary data suggests there is a transfer of compensation towards the lower limbs; as PI-LL increases and pelvic retroversion is maximized.
Journal of neurosurgery. Spine, Jan 13, 2015
OBJECT Previous forceplate studies analyzing the impact of sagittal-plane spinal deformity on pel... more OBJECT Previous forceplate studies analyzing the impact of sagittal-plane spinal deformity on pelvic parameters have demonstrated the compensatory mechanisms of pelvis translation in addition to rotation. However, the mechanisms recruited for this pelvic rotation were not assessed. This study aims to analyze the relationship between spinopelvic and lower-extremity parameters and clarify the role of pelvic translation. METHODS This is a retrospective study of patients with spinal deformity and full-body EOS images. Patients with only stenosis or low-back pain were excluded. Patients were grouped according to T-1 spinopelvic inclination (T1SPi): sagittal forward (forward, > 0.5°), neutral (-6.3° to 0.5°), or backward (< -6.3°). Pelvic translation was quantified by pelvic shift (sagittal offset between the posterosuperior corner of the sacrum and anterior cortex of the distal tibia), hip extension was measured using the sacrofemoral angle (SFA; the angle formed by the middle of t...
The spine journal : official journal of the North American Spine Society, Jan 30, 2015
Adult spinal deformity (ASD) patients may gain a MCID in one or more of the HRQOL instruments wit... more Adult spinal deformity (ASD) patients may gain a MCID in one or more of the HRQOL instruments without surgical intervention. This study identifies baseline characteristics of this subset of non-operative patients and proposes predictors of those most likely to benefit. Determine factors that affect likelihood of non-operative patients to reach minimum clinically important difference (MCID). Retrospective review of prospective, multi-center database. Non-operative ASD patients. Health-related quality of life measures (HRQOL), including the Scoliosis Research Society (SRS)-22 questionnaire. Multicenter database of 215 non-operative patients with ASD and minimum 2-year follow-up. Using a multivariate analysis, two groups were compared to identify possible predictors: those that reached an MCID in SRS Pain or Activity (n=86) at 2 years, and those who did not reach MCID (n=129). Subgroup multivariate analysis of patients with a deficit (potential improvement) in both SRS Pain and Activit...
Sagittal alignment, often misrepresented as sagittal balance, describes the ideal and “normal” al... more Sagittal alignment, often misrepresented as sagittal balance, describes the ideal and “normal” alignment in the sagittal plane, resulting from the interplay between various organic factors. Any pathology that alters this equilibrium instigates sagittal malalignment and its compensatory mechanisms. As a result, sagittal malalignment is not limited to adult spinal deformity; its pervasiveness extends through most spinal disorders. While further research is developing, the literature reports clinically relevant radio-graphic parameters that have significant relationships with patient-reported outcomes. This article aims to provide a pragmatic review of sagittal plane analysis. At the end of this review, the reader should be able to analyze the sagittal plane of the spine, identify compensatory mechanisms, and choose patient-specific alignment targets.
STUDY DESIGN:
Retrospective review of a prospectively collected database.
OBJECTIVE:
This study ... more STUDY DESIGN:
Retrospective review of a prospectively collected database.
OBJECTIVE:
This study compares patient demographics, incidence of comorbidities, procedure-related complications, and mortality following primary vs. revision adult spinal deformity surgerySummary of Background Data. While adult spinal deformity (ASD) surgery has been extensively investigated, no previous study has provided nationwide estimates of patient characteristics and procedure-related complications for primary vs. revision spinal deformity surgery comparatively.
METHODS:
Nationwide Inpatient Sample data collected between 2001 and 2010 was analyzed. Discharges with procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included for patients aged 25+ and 4+ levels fused with any diagnoses specific for scoliosis. Patient demographics, comorbidity and procedure-related complications incidence were determined for primary vs. revision cohorts. Multivariate analysis reported as (OR [95% CI]).
RESULTS:
Discharges for 9133 primary and 850 revision cases were identified. Patients differed on the basis of demographic and hospital data. Average comorbidity indices for the cohorts were similar (p = 0.580), as was in-hospital mortality (p = 0.163). The incidence of procedure-related complications was higher for the revision cohort (46.96% vs. 71.97%, p = 0.001). The mean hospital course for the revision cohort was longer (6.37 vs. 7.13 days, p<0.0001). Revisions had an increased risk of complications involving the nervous system (1.34[1.10-1.6]), hematoma/seroma formation (2.31[1.92-2.78]), accidental vessel or nerve puncture (1.44[1.29-1.61]), wound dehiscence (2.18[1.48-3.21]), post-op infection (3.10[2.50-3.85]) and ARDS complications (1.43[1.28-1.60]). The primary cohort had a decreased risk for GI (0.65[0.55-0.76]) and GU complications (0.71[0.51-0.99]).
CONCLUSIONS:
Relative to primary cases, those undergoing revision correction of spinal deformity have a higher risk of many procedure-related complications with a longer hospital course despite similar baseline comorbidity burden and in-hospital mortality rate. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality and direct future research to improve outcomes.
OBJECT Adult spinal deformity (ASD) surgery is known for its high complication rate. This study e... more OBJECT Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD. METHODS This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders. RESULTS Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001). CONCLUSIONS This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.
INTRODUCTION:
In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory s... more INTRODUCTION:
In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory subluxation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis. Stereoradiography, recently developed for medical applications, provides full-body standing radiographs and 3D reconstruction of the spine, with low radiation dose.
HYPOTHESIS:
3D stereoradiography improves analysis of RS and of its relations with transverse plane and spinopelvic parameters and clinical impact.
MATERIAL AND METHODS:
One hundred and thirty adults with lumbar ASD and full-spine EOS® radiographs (EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in the coronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation (apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS (lateral listhesis>5mm) and without RS (without lateral listhesis exceeding 5mm: non-RS). Correlations between radiologic and clinical data were assessed.
RESULTS:
RS patients were significantly older, with larger Cobb angle (37.4° vs. 26.6°, P=0.0001), more severe sagittal deformity, and greater apex AVR and TI (respectively: 22.9° vs. 11.3°, P<0.001; and 41.0° vs. 19.9°, P<0.001). Ten percent of patients had AIR>10° without visible RS on 2D radiographs. RS patients reported significantly more frequent low back pain and radiculalgia.
DISCUSSION:
In this EOS® study, ASD patients with RS had greater coronal curvature and sagittal and transverse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosis and prognosis to guide management.
PURPOSE:
This nationwide study identifies ASD surgical risk factors for morbidity/mortality.
MET... more PURPOSE:
This nationwide study identifies ASD surgical risk factors for morbidity/mortality.
METHODS:
NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as [OR (95 % CI)].
RESULTS:
11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28 %, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) [1.62 (1.42-1.84)] [5.67 (3.30-9.73)], coagulopathy [3.52 (3.22-3.85)] [2.32 (1.44-3.76)], electrolyte imbalance [2.65 (2.52-2.79)] [4.63 (3.15-6.81)], pulmonary circulation disorders [9.45 (7.45-11.99)] [8.94 (4.43-18.03)], renal failure [1.29 (1.13-1.47)] [5.51 (2.57-11.82)], and pathologic weight loss [2.38 (2.01-2.81)] [7.28 (4.36-12.14)]. Chronic pulmonary disease was associated with higher morbidity [1.08 (1.02-1.14)]; liver disease was linked to increased mortality [36.09 (16.16-80.59)]. 9+ level fusions had increased morbidity vs 4-8 level fusions [1.69 (1.61-1.78)] and refusions [1.08 (1.02-1.14)]. Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups [0.85 (0.80-0.91)]. Age >65 was associated with increased morbidity and mortality vs 25-64 group [1.09 (1.05-1.14)] [3.49 (2.31-5.29)]. Females had increased morbidity [1.18 (1.13-1.23)] and decreased mortality [0.30 (0.21-0.44)]. Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (P < 0.0001).
CONCLUSIONS:
Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.
Study Design. Retrospective review, full body radiographic analysis of adult patients with sagitt... more Study Design. Retrospective review, full body radiographic analysis of adult patients with sagittal spinal malalignment.Objective. Investigate the compensatory mechanisms involved in the sagittal plane of the body following progressive spinal sagittal malalignment, and study the impact of age on compensatory mechanisms recruitment.Summary of Background Data. Sagittal spinal malalignment (SSM) patients recruit compensatory mechanisms to maintain erect posture and horizontal gaze. Mechanisms such as pelvic retroversion, knee flexion and pelvic shift have been proposed, but how they contribute and how age affects their recruitment is poorly understood.Methods. Retrospective review of adult SSM patients who underwent full standing axis stereoradiography EOS©. Radiographic measurements were performed with Surgimap©. Patients were categorized based on the mismatch between pelvic incidence and lumbar lordosis (PI-LL). Compensatory mechanisms were normalized to each patient's PI-LL and compared by mismatch groups. In addition, patients were subcategorized into two age groups (≥65yrs and <65yrs) and compared within the same groups of mismatch.Results. 161 patients with a mean age of 62.93±12.8yrs. Mean SVA 62.3±61.5mm, PT 29.2±8.4°, and PI-LL 21.0±14.9°. Mismatch groups were: Group 1: PI-LL 0-10°, Group 2: 10-20°, Group 3: 20-30°, and Group 4: > 30°. There were significant differences between all groups in regards to thoracic kyphosis (TK), pelvic tilt (PT), knee flexion angle (KA), and pelvic shift (P.Sh) by ANOVA (p<0.001). As PI-LL increased, TK and PT contribution to the compensation cascade decreased and KA and P.Sh contribution increased. Patients with PI-LL of > 30° who were older had significantly less PT and more TK than patients with similar PI-LL who were younger.Conclusions. Spino-pelvic mismatch is an important driver in SSM. Pelvic retroversion and flattening of thoracic kyphosis (reduction) become exhausted with increasing mismatch, at which point there appears to be a steady transfer of compensation towards significant participation of the lower limbs. Further analysis suggests differential recruitment of these compensatory mechanisms based upon age.
Degenerative changes have the potential to greatly disrupt the normal curvature of the spine, lea... more Degenerative changes have the potential to greatly disrupt the normal curvature of the spine, leading to sagittal malalignment. This phenomenon is often treated with operative modalities, such as osteotomies, though even with surgery, only one-third of patients may reach neutral alignment. Improvement in surgical outcomes may be achieved through better understanding of radiographic spino-pelvic parameters and their association with deformity. Methodical surgical planning, including selection of levels of instrumentation and site of the osteotomy, is crucial in determining the optimal plan for a patient's specific pathology and may minimize risk of developing postoperative proximal junctional kyphosis/failure. While sagittal alignment is essential in operative strategy, the coronal plane should not be overlooked, as it may affect the osteotomy technique. The concepts of sagittal balance and alignment are further complicated in patients with neuromuscular diseases such as Parkinson's disease, and appreciation of the interplay between anatomic and postural deformities is necessary to properly treat these patients. Finally, given the importance of sagittal alignment and the role of osteotomies in treatment for deformity, the need for future research becomes apparent. Novel intraoperative measurement techniques and three-dimensional analysis of the spine may allow for vastly improved operative correction. Furthermore, awareness of the relationship between alignment and balance, the soft tissue envelope, and compensatory mechanisms will provide a more comprehensive conception of the nature of spinal deformity and the modalities with which it is treated
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Papers by Bassel G. Diebo
Retrospective review of a prospectively collected database.
OBJECTIVE:
This study compares patient demographics, incidence of comorbidities, procedure-related complications, and mortality following primary vs. revision adult spinal deformity surgerySummary of Background Data. While adult spinal deformity (ASD) surgery has been extensively investigated, no previous study has provided nationwide estimates of patient characteristics and procedure-related complications for primary vs. revision spinal deformity surgery comparatively.
METHODS:
Nationwide Inpatient Sample data collected between 2001 and 2010 was analyzed. Discharges with procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included for patients aged 25+ and 4+ levels fused with any diagnoses specific for scoliosis. Patient demographics, comorbidity and procedure-related complications incidence were determined for primary vs. revision cohorts. Multivariate analysis reported as (OR [95% CI]).
RESULTS:
Discharges for 9133 primary and 850 revision cases were identified. Patients differed on the basis of demographic and hospital data. Average comorbidity indices for the cohorts were similar (p = 0.580), as was in-hospital mortality (p = 0.163). The incidence of procedure-related complications was higher for the revision cohort (46.96% vs. 71.97%, p = 0.001). The mean hospital course for the revision cohort was longer (6.37 vs. 7.13 days, p<0.0001). Revisions had an increased risk of complications involving the nervous system (1.34[1.10-1.6]), hematoma/seroma formation (2.31[1.92-2.78]), accidental vessel or nerve puncture (1.44[1.29-1.61]), wound dehiscence (2.18[1.48-3.21]), post-op infection (3.10[2.50-3.85]) and ARDS complications (1.43[1.28-1.60]). The primary cohort had a decreased risk for GI (0.65[0.55-0.76]) and GU complications (0.71[0.51-0.99]).
CONCLUSIONS:
Relative to primary cases, those undergoing revision correction of spinal deformity have a higher risk of many procedure-related complications with a longer hospital course despite similar baseline comorbidity burden and in-hospital mortality rate. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality and direct future research to improve outcomes.
In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory subluxation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis. Stereoradiography, recently developed for medical applications, provides full-body standing radiographs and 3D reconstruction of the spine, with low radiation dose.
HYPOTHESIS:
3D stereoradiography improves analysis of RS and of its relations with transverse plane and spinopelvic parameters and clinical impact.
MATERIAL AND METHODS:
One hundred and thirty adults with lumbar ASD and full-spine EOS® radiographs (EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in the coronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation (apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS (lateral listhesis>5mm) and without RS (without lateral listhesis exceeding 5mm: non-RS). Correlations between radiologic and clinical data were assessed.
RESULTS:
RS patients were significantly older, with larger Cobb angle (37.4° vs. 26.6°, P=0.0001), more severe sagittal deformity, and greater apex AVR and TI (respectively: 22.9° vs. 11.3°, P<0.001; and 41.0° vs. 19.9°, P<0.001). Ten percent of patients had AIR>10° without visible RS on 2D radiographs. RS patients reported significantly more frequent low back pain and radiculalgia.
DISCUSSION:
In this EOS® study, ASD patients with RS had greater coronal curvature and sagittal and transverse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosis and prognosis to guide management.
This nationwide study identifies ASD surgical risk factors for morbidity/mortality.
METHODS:
NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as [OR (95 % CI)].
RESULTS:
11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28 %, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) [1.62 (1.42-1.84)] [5.67 (3.30-9.73)], coagulopathy [3.52 (3.22-3.85)] [2.32 (1.44-3.76)], electrolyte imbalance [2.65 (2.52-2.79)] [4.63 (3.15-6.81)], pulmonary circulation disorders [9.45 (7.45-11.99)] [8.94 (4.43-18.03)], renal failure [1.29 (1.13-1.47)] [5.51 (2.57-11.82)], and pathologic weight loss [2.38 (2.01-2.81)] [7.28 (4.36-12.14)]. Chronic pulmonary disease was associated with higher morbidity [1.08 (1.02-1.14)]; liver disease was linked to increased mortality [36.09 (16.16-80.59)]. 9+ level fusions had increased morbidity vs 4-8 level fusions [1.69 (1.61-1.78)] and refusions [1.08 (1.02-1.14)]. Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups [0.85 (0.80-0.91)]. Age >65 was associated with increased morbidity and mortality vs 25-64 group [1.09 (1.05-1.14)] [3.49 (2.31-5.29)]. Females had increased morbidity [1.18 (1.13-1.23)] and decreased mortality [0.30 (0.21-0.44)]. Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (P < 0.0001).
CONCLUSIONS:
Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.
Retrospective review of a prospectively collected database.
OBJECTIVE:
This study compares patient demographics, incidence of comorbidities, procedure-related complications, and mortality following primary vs. revision adult spinal deformity surgerySummary of Background Data. While adult spinal deformity (ASD) surgery has been extensively investigated, no previous study has provided nationwide estimates of patient characteristics and procedure-related complications for primary vs. revision spinal deformity surgery comparatively.
METHODS:
Nationwide Inpatient Sample data collected between 2001 and 2010 was analyzed. Discharges with procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included for patients aged 25+ and 4+ levels fused with any diagnoses specific for scoliosis. Patient demographics, comorbidity and procedure-related complications incidence were determined for primary vs. revision cohorts. Multivariate analysis reported as (OR [95% CI]).
RESULTS:
Discharges for 9133 primary and 850 revision cases were identified. Patients differed on the basis of demographic and hospital data. Average comorbidity indices for the cohorts were similar (p = 0.580), as was in-hospital mortality (p = 0.163). The incidence of procedure-related complications was higher for the revision cohort (46.96% vs. 71.97%, p = 0.001). The mean hospital course for the revision cohort was longer (6.37 vs. 7.13 days, p<0.0001). Revisions had an increased risk of complications involving the nervous system (1.34[1.10-1.6]), hematoma/seroma formation (2.31[1.92-2.78]), accidental vessel or nerve puncture (1.44[1.29-1.61]), wound dehiscence (2.18[1.48-3.21]), post-op infection (3.10[2.50-3.85]) and ARDS complications (1.43[1.28-1.60]). The primary cohort had a decreased risk for GI (0.65[0.55-0.76]) and GU complications (0.71[0.51-0.99]).
CONCLUSIONS:
Relative to primary cases, those undergoing revision correction of spinal deformity have a higher risk of many procedure-related complications with a longer hospital course despite similar baseline comorbidity burden and in-hospital mortality rate. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality and direct future research to improve outcomes.
In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory subluxation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis. Stereoradiography, recently developed for medical applications, provides full-body standing radiographs and 3D reconstruction of the spine, with low radiation dose.
HYPOTHESIS:
3D stereoradiography improves analysis of RS and of its relations with transverse plane and spinopelvic parameters and clinical impact.
MATERIAL AND METHODS:
One hundred and thirty adults with lumbar ASD and full-spine EOS® radiographs (EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in the coronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation (apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS (lateral listhesis>5mm) and without RS (without lateral listhesis exceeding 5mm: non-RS). Correlations between radiologic and clinical data were assessed.
RESULTS:
RS patients were significantly older, with larger Cobb angle (37.4° vs. 26.6°, P=0.0001), more severe sagittal deformity, and greater apex AVR and TI (respectively: 22.9° vs. 11.3°, P<0.001; and 41.0° vs. 19.9°, P<0.001). Ten percent of patients had AIR>10° without visible RS on 2D radiographs. RS patients reported significantly more frequent low back pain and radiculalgia.
DISCUSSION:
In this EOS® study, ASD patients with RS had greater coronal curvature and sagittal and transverse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosis and prognosis to guide management.
This nationwide study identifies ASD surgical risk factors for morbidity/mortality.
METHODS:
NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as [OR (95 % CI)].
RESULTS:
11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28 %, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) [1.62 (1.42-1.84)] [5.67 (3.30-9.73)], coagulopathy [3.52 (3.22-3.85)] [2.32 (1.44-3.76)], electrolyte imbalance [2.65 (2.52-2.79)] [4.63 (3.15-6.81)], pulmonary circulation disorders [9.45 (7.45-11.99)] [8.94 (4.43-18.03)], renal failure [1.29 (1.13-1.47)] [5.51 (2.57-11.82)], and pathologic weight loss [2.38 (2.01-2.81)] [7.28 (4.36-12.14)]. Chronic pulmonary disease was associated with higher morbidity [1.08 (1.02-1.14)]; liver disease was linked to increased mortality [36.09 (16.16-80.59)]. 9+ level fusions had increased morbidity vs 4-8 level fusions [1.69 (1.61-1.78)] and refusions [1.08 (1.02-1.14)]. Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups [0.85 (0.80-0.91)]. Age >65 was associated with increased morbidity and mortality vs 25-64 group [1.09 (1.05-1.14)] [3.49 (2.31-5.29)]. Females had increased morbidity [1.18 (1.13-1.23)] and decreased mortality [0.30 (0.21-0.44)]. Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (P < 0.0001).
CONCLUSIONS:
Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.