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  1. Article: Clinical and Economic Impact of Proximal Junctional Kyphosis on Pediatric and Adult Spinal Deformity Patients.

    Hostin, Richard A / Yeramaneni, Samrat / Gum, Jeffrey L / Smith, Justin S

    International journal of spine surgery

    2023  Volume 17, Issue S2, Page(s) S9–S17

    Abstract: The common goal of pediatric and adult spinal reconstructive procedures is to minimize long-term risk of disability, pain, and mortality. A common complication that has proved particularly problematic in the adult spinal deformity population and that has ...

    Abstract The common goal of pediatric and adult spinal reconstructive procedures is to minimize long-term risk of disability, pain, and mortality. A common complication that has proved particularly problematic in the adult spinal deformity population and that has been an area of increased research and clinical focus is proximal junctional kyphosis (PJK). The incidence of PJK ranges from 10%-40% based on criteria used to define the condition. Clinically, PJK complication is associated with increased pain, decreased self-image and Scoliosis Research Society scores, and severe neurological injuries affecting the patient's quality of life. Economically, direct costs of PJK complication-associated revision surgery ranges from $20,000 to $120,000, which places an enormous burden on patients, providers, and payers. To mitigate the risk of PJK occurrence postoperatively, it is paramount to develop consistent guidelines in defining and classifying PJK in addition to extensive preoperative planning and risk stratification that is patient specific. This article will provide an overview on the clinical and economic impact of PJK in pediatric and adult spine deformity patients with an emphasis on the role of patient factors and predictive analytics, challenges in developing a consistent PJK classification, and current treatment and prevention strategies.
    Language English
    Publishing date 2023-10-05
    Publishing country Netherlands
    Document type Journal Article
    ISSN 2211-4599
    ISSN 2211-4599
    DOI 10.14444/8518
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  2. Article ; Online: Early Detection of Scoliosis-What the USPSTF "I" Means for Us.

    Hresko, M Timothy / Schwend, Richard M / Hostin, Richard A

    JAMA pediatrics

    2018  Volume 172, Issue 3, Page(s) 216–217

    MeSH term(s) Adolescent ; Early Diagnosis ; Humans ; Mass Screening ; Preventive Health Services ; Scoliosis
    Language English
    Publishing date 2018-01-06
    Publishing country United States
    Document type Editorial ; Comment
    ZDB-ID 2701223-2
    ISSN 2168-6211 ; 2168-6203
    ISSN (online) 2168-6211
    ISSN 2168-6203
    DOI 10.1001/jamapediatrics.2017.5585
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  3. Article ; Online: Scoliosis Research Society survey: brace management in adolescent idiopathic scoliosis.

    Halsey, Matthew / Dolan, Lori A / Hostin, Richard A / Adobor, Raphael D / Dayer, Romain / Dema, Eugenio / Letaif, Olavo B

    Spine deformity

    2021  Volume 9, Issue 3, Page(s) 697–702

    Abstract: Purpose: While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of ... ...

    Abstract Purpose: While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management.
    Methods: 1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring. Free-text responses were analyzed and collated into common themes. Data were analyzed using Microsoft Excel 2013.
    Results: Of 218 respondents; 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing. 99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both %-Cobb correction and fit criteria to evaluate brace adequacy. In contrast, other aspects of brace management demonstrated a high degree of practice variability. This was seen with a radiographic assessment of maturity level, hours prescribed, timing and frequency of radiographic evaluation, the use of nighttime bracing only, and the method and timing of brace discontinuation.
    Conclusion: Although there is consensus in brace management amongst SRS members with respect to brace initiation and evaluation of adequacy, there is striking variability in how bracing for AIS is used. This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS.
    Level of evidence: III.
    MeSH term(s) Adolescent ; Braces ; Consensus ; Humans ; Kyphosis ; Scoliosis/diagnostic imaging ; Scoliosis/therapy ; Societies
    Language English
    Publishing date 2021-02-12
    Publishing country England
    Document type Journal Article
    ZDB-ID 2717704-X
    ISSN 2212-1358 ; 2212-134X ; 2212-1358
    ISSN (online) 2212-1358 ; 2212-134X
    ISSN 2212-1358
    DOI 10.1007/s43390-020-00265-4
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  4. Article ; Online: Return to work after adult spinal deformity surgery.

    Neuman, Brian J / Wang, Kevin Y / Harris, Andrew B / Raad, Micheal / Hostin, Richard A / Protopsaltis, Themisctocles S / Ames, Christopher P / Passias, Peter G / Gupta, Munish C / Klineberg, Eric O / Hart, Robert / Bess, Shay / Kebaish, Khaled M

    Spine deformity

    2022  Volume 11, Issue 1, Page(s) 197–204

    Abstract: Purpose: To determine the proportions of patients returning to work at various points after adult spinal deformity (ASD) surgery and the associations between surgical invasiveness and time to return to work.: Methods: Using a multicenter database of ... ...

    Abstract Purpose: To determine the proportions of patients returning to work at various points after adult spinal deformity (ASD) surgery and the associations between surgical invasiveness and time to return to work.
    Methods: Using a multicenter database of patients treated surgically for ASD from 2008 to 2015, we identified 188 patients (mean age 51 ± 15 years) who self-reported as employed preoperatively and had 2-year follow-up. Per the ASD-Surgical and Radiographical Invasiveness Index (ASD-SR), 118 patients (63%) underwent high-invasiveness (HI) surgery (ASD-SR ≥ 100) and 70 (37%) had low-invasiveness (LI) surgery (ASD-SR < 100). Patients who self-reported ≥ 75% normal level of work/school activity were considered to be working full time. Chi-squared and Fisher exact tests were used to compare categorical variables (α = .05).
    Results: Preoperatively, 69% of employed patients worked full time. Postoperatively, 15% of employed patients were full time at 6 weeks, 70% at 6 months, 83% at 1 year, and 84% at 2 years. Percentage of employed patients working full time at 2 years was greater than preoperatively (p < .001); percentage of patients returning to full time at 6 weeks was lower in the HI (5%) than in the LI group (19%) (p = .03), a difference not significant at later points.
    Conclusions: Most adults returned to full-time work after ASD surgery. A smaller percentage of patients in the HI group than in the LI group returned to full-time work at 6 weeks. Patients employed full time preoperatively will likely return to full-time employment after ASD surgery.
    Level of evidence: III.
    MeSH term(s) Humans ; Adult ; Middle Aged ; Aged ; Return to Work ; Postoperative Complications/etiology ; Self Report ; Radiography ; Spinal Fusion/adverse effects
    Language English
    Publishing date 2022-10-11
    Publishing country England
    Document type Multicenter Study ; Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 2717704-X
    ISSN 2212-1358 ; 2212-134X ; 2212-1358
    ISSN (online) 2212-1358 ; 2212-134X
    ISSN 2212-1358
    DOI 10.1007/s43390-022-00552-2
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  5. Article ; Online: Fractional Curve in Adult Spinal Deformity: Is it a Driver of or a Compensation for Coronal Malalignment?

    Plais, Nicolas / Bao, Hongda / Lafage, Renaud / Kim, Han Jo / Gupta, Munish / Smith, Justin S / Shaffrey, Christopher / Mundis, Gregory / Burton, Douglas / Ames, Christopher / Klineberg, Eric / Bess, Shay / Hostin, Richard A / Schwab, Frank / Lafage, Virginie

    Clinical spine surgery

    2021  Volume 34, Issue 5, Page(s) E276–E281

    Abstract: Study design: This was a retrospective review of the multicenter adult spine deformity database.: Objective: The objective of this study was to investigate the role of the fractional curve (FC) on global coronal malalignment.: Summary of background ...

    Abstract Study design: This was a retrospective review of the multicenter adult spine deformity database.
    Objective: The objective of this study was to investigate the role of the fractional curve (FC) on global coronal malalignment.
    Summary of background data: Despite being very common, the role of the coronal FC as either a driver or compensation for global coronal malalignment is not well documented.
    Materials and methods: Patients with the following characteristics were extracted from a prospective multicenter database: lumbar/thoracolumbar (TL) major coronal curve >15 degrees, apex at T11-L3, lower end vertebra at L3 or L4, above 45 years old, and FC >5 degrees. In addition to the classic radiographic parameters, baseline analysis included Cobb angle, pelvic obliquity (PO), fractional ratio (fractional Cobb/main Cobb), the sum of PO and FC, as well as the coronal Qiu classification. Curves distribution (TL vs. FC) were compared across the 3 Qui types, and the role of the FC was investigated.
    Results: A total of 404 patients (63 y old, 83.3% female) were included: 43 patients were classified as type B, 120 as type C, and 241 were coronally balanced (type A). Compared with the balanced patients, type C patients had similar major TL Cobb angles but significantly larger fractional Cobb angles (17.5 vs. 22.3 degrees, P<0.001). By opposition, type B patients had significantly larger major TL Cobb angles (49 vs. 41 degrees, P=0.001) but smaller fractional Cobb angles (P<0.001). PO>5 degrees in the same direction as FC was more common in type B patients (20%) than in type C patients (7.5%), which suggests the preferential role of pelvic compensation.
    Conclusions: Our findings challenge the idea that FC is only a compensatory curve below a main lumbar or TL curve. In type B patients, FC acts as a compensation mechanism but fails to maintain coronal alignment despite the presence of PO. In type C patients, however, the lumbosacral FC acts as a primary driver of coronal malalignment.
    Level of evidence: Level III.
    Language English
    Publishing date 2021-03-12
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2849646-2
    ISSN 2380-0194 ; 2380-0186
    ISSN (online) 2380-0194
    ISSN 2380-0186
    DOI 10.1097/BSD.0000000000001151
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    Zs.A 2427: Show issues Location:
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  6. Article ; Online: Reaching the medicare allowable threshold in adult spinal deformity surgery: multicenter cost analysis comparing actual direct hospital costs versus what the government will pay.

    Gum, Jeffrey L / Line, Breton / Carreon, Leah Y / Hostin, Richard A / Yeramaneni, Samrat / Glassman, Steven D / Burton, Douglas L / Smith, Justin S / Shaffrey, Christopher I / Passias, Peter G / Lafage, Virginie / Ames, Christopher P / Shay Bess, R

    Spine deformity

    2021  Volume 10, Issue 2, Page(s) 425–431

    Abstract: Study design: Retrospective multicenter cost analysis.: Objective: To (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can ... ...

    Abstract Study design: Retrospective multicenter cost analysis.
    Objective: To (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can predict iEOC cases that are below MA. Previous studies have suggested that actual direct hospital cost of Adult Spinal Deformity (ASD) surgery is higher than Medicare Allowable (MA) rates, which has become the benchmark reimbursement target for hospital accounting systems.
    Methods: From a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions (> 5 level) with cost data were identified. iEOC cost was calculated utilizing actual direct hospital cost. MA rates were calculated using hospital specific, year-appropriate CMS Inpatient Pricer Payment System. Recursive partitioning identified potentially modifiable variables that can predict iEOC cost < MA.
    Results: Administrative direct cost data from 210 patients were obtained from 4 of 11 centers. Ninety-five (45%) patients had iEOC cost < MA. There was significant variation across the four centers in both iEOC cost ($56,788-$78,878, p < 0.0001) and reimbursement ($40,623-$91,351, p < 0.0001) across deformity-specific DRGs (453,454,456,457). Academic centers were more likely to have iEOC costs < MA (67.2% vs 8.9%, p < 0.0001). Recursive partitioning (r
    Conclusion: There is significant institutional (private vs academic) variation in ASD reimbursement. BMP use, deformity type, approach, and baseline mental health impact ASD surgery cost being below Medicare reimbursement. ASD surgeries with anterior/posterior approaches are in DRGs that can potentially reimburse 2.2-fold the posterior-only surgery, making it more likely to fall below the MA threshold.
    Level of evidence: III.
    MeSH term(s) Adult ; Aged ; Government ; Hospital Costs ; Hospitals ; Humans ; Medicare ; Prospective Studies ; Retrospective Studies ; Spinal Fusion ; United States
    Language English
    Publishing date 2021-09-01
    Publishing country England
    Document type Journal Article ; Multicenter Study ; Research Support, Non-U.S. Gov't
    ZDB-ID 2717704-X
    ISSN 2212-1358 ; 2212-134X ; 2212-1358
    ISSN (online) 2212-1358 ; 2212-134X
    ISSN 2212-1358
    DOI 10.1007/s43390-021-00405-4
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  7. Article ; Online: Impact of Readmissions in Episodic Care of Adult Spinal Deformity: Event-Based Cost Analysis of 695 Consecutive Cases.

    Yeramaneni, Samrat / Gum, Jeffrey L / Carreon, Leah Y / Klineberg, Eric O / Smith, Justin S / Jain, Amit / Hostin, Richard A

    The Journal of bone and joint surgery. American volume

    2018  Volume 100, Issue 6, Page(s) 487–495

    Abstract: Background: Readmissions following adult spinal deformity surgical procedures frequently occur, placing a substantial burden on patients and providers. Existing literature on readmission costs, including reason-specific readmission costs, is limited. ... ...

    Abstract Background: Readmissions following adult spinal deformity surgical procedures frequently occur, placing a substantial burden on patients and providers. Existing literature on readmission costs, including reason-specific readmission costs, is limited. The purposes of this study were to determine the most expensive reasons for readmission, to assess the impact of reasons and timing on readmission costs, and to estimate the drivers of total costs associated with adult spinal deformity surgical procedures.
    Methods: We performed a retrospective review of 695 patients with adult spinal deformity (≥18 years of age) who underwent a corrective spine surgical procedure at a single center from 2005 to 2013. Demographic, surgical, and direct cost data expressed in 2010 dollars for the entire inpatient episode of care were obtained from the hospital administrative database. A multivariable linear regression model with a gamma distribution and log-link function was used to estimate the impact of reasons and timing on readmission costs and to identify the primary drivers of long-term costs.
    Results: The mean age (and standard deviation) of the patients was 50.6 ± 15.8 years, 589 patients (85%) were women, and 637 patients (92%) were Caucasian. The observed readmission rates were 24% overall (costing $10.1 million), 8.8% for 30 days (costing $3.2 million), and 11.7% for 90 days (costing $4.6 million). The most expensive readmissions and their mean readmission cost were pseudarthrosis ($92,755), infection ($75,172), and proximal junctional kyphosis ($66,713), after adjusting for patient and surgical factors. The mean readmission cost after 2 years was $86,081. Older age (p = 0.001), ≥8 levels fused (p = 0.01), and length of index stay at the hospital (p < 0.0001) were independently associated with higher total cost. Surgical procedures in patients with a thoracic-only curve (p = 0.004) or a double curve (p = 0.05) and a surgical approach that was anterior-only (p < 0.0001) or posterior-only (p = 0.01) were independently associated with lower total costs.
    Conclusions: Compared with readmission cost due to medical reasons, readmission due to pseudarthrosis increases mean readmission cost by 105%, readmission due to infection increases mean readmission cost by 72%, and readmission due to proximal junctional kyphosis increases mean readmission cost by 63%. Together, these 3 reasons accounted for 73% of readmission costs. This study identifies potential areas for cost reduction and opportunities for reducing readmission rates.
    Clinical relevance: Although reducing the 30-day and 90-day readmission rates and costs are important; adult spinal deformity surgery is unique, because the most common and most expensive complications occur after 1 year. We believe that our paper is clinically relevant as it will help to guide clinical focus on the most impactful complications.
    MeSH term(s) Adult ; Aged ; Costs and Cost Analysis ; Episode of Care ; Female ; Hospital Costs ; Humans ; Kyphosis/surgery ; Male ; Middle Aged ; Patient Readmission/economics ; Retrospective Studies ; Scoliosis/surgery
    Language English
    Publishing date 2018-03-20
    Publishing country United States
    Document type Journal Article
    ZDB-ID 220625-0
    ISSN 1535-1386 ; 0021-9355
    ISSN (online) 1535-1386
    ISSN 0021-9355
    DOI 10.2106/JBJS.16.01589
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  8. Article ; Online: Defining a Surgical Invasiveness Threshold for Increased Risk of a Major Complication Following Adult Spinal Deformity Surgery.

    Neuman, Brian J / Harris, Andrew B / Klineberg, Eric O / Hostin, Richard A / Protopsaltis, Themistocles S / Passias, Peter G / Gum, Jeffrey L / Hart, Robert A / Kelly, Michael P / Daniels, Alan H / Ames, Christopher P / Shaffrey, Christopher I / Kebaish, Khaled M

    Spine

    2021  Volume 46, Issue 14, Page(s) 931–938

    Abstract: Study design: Retrospective review.: Objectives: The aim of this study was to define a surgical invasiveness threshold that predicts major complications after adult spinal deformity (ASD) surgery; use this threshold to categorize patients into ... ...

    Abstract Study design: Retrospective review.
    Objectives: The aim of this study was to define a surgical invasiveness threshold that predicts major complications after adult spinal deformity (ASD) surgery; use this threshold to categorize patients into quartiles by invasiveness; and determine the odds of major complications by quartile.
    Summary of background data: Understanding the relationship between surgical invasiveness and major complications is important for estimating the likelihood of major complications after ASD surgery.
    Methods: Using a multicenter database, we identified 574 ASD patients (more than 5 levels fused; mean age, 60 ± 15 years) with minimum 2-year follow-up. Invasiveness was calculated as the ASD Surgical and Radiographic (ASD-SR) score. Youden index was used to identify the invasiveness score cut-off associated with optimal sensitivity and specificity for predicting major complications. Resulting high- and low-invasiveness groups were divided in half to create quartiles. Odds of developing a major complication were analyzed for each quartile using logistic regression (alpha = 0.05).
    Results: The ASD-SR cutoff score that maximally predicted major complications was 90 points. ASD-SR quartiles were 0 to 65 (Q1), 66 to 89 (Q2), 90 to 119 (Q3), and ≥120 (Q4). Risk of a major complication was 17% in Q1, 21% in Q2, 35% in Q3, and 33% in Q4 (P < 0.001). Comparisons of adjacent quartiles showed an increase in the odds of a major complication from Q2 to Q3 (odds ratio [OR] 1.8; 95% confidence interval [CI]: 1.0-3.0), but not from Q1 to Q2 or from Q3 to Q4. Patients with ASD-SR scores ≥90 were 1.9 times as likely to have a major complication than patients with scores <90 (OR 1.9, 95% CI 1.3-2.9). Mean ASD-SR scores above and below 90 points were 121 ± 25 and 63 ± 17, respectively.
    Conclusion: The odds of major complications after ASD surgery are significantly greater when the procedure has an ASD-SR score ≥90. ASD-SR score can be used to counsel patients regarding these increased odds.Level of Evidence: 3.
    MeSH term(s) Aged ; Humans ; Middle Aged ; Orthopedic Procedures/adverse effects ; Postoperative Complications/epidemiology ; Retrospective Studies ; Spinal Diseases/surgery ; Spine/surgery
    Language English
    Publishing date 2021-06-16
    Publishing country United States
    Document type Journal Article
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/BRS.0000000000003949
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  9. Article: Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery.

    Passias, Peter G / Williamson, Tyler K / Mir, Jamshaid M / Smith, Justin S / Lafage, Virginie / Lafage, Renaud / Line, Breton / Daniels, Alan H / Gum, Jeffrey L / Schoenfeld, Andrew J / Hamilton, David Kojo / Soroceanu, Alex / Scheer, Justin K / Eastlack, Robert / Mundis, Gregory M / Diebo, Bassel / Kebaish, Khaled M / Hostin, Richard A / Gupta, Munish C /
    Kim, Han Jo / Klineberg, Eric O / Ames, Christopher P / Hart, Robert A / Burton, Douglas C / Schwab, Frank J / Shaffrey, Christopher I / Bess, Shay / On Behalf Of The International Spine Study Group

    Journal of clinical medicine

    2023  Volume 12, Issue 17

    Abstract: Background: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.: Objective: Compare long-term ... ...

    Abstract Background: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.
    Objective: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers.
    Study design/setting: Retrospective cohort study of a prospectively collected multicenter database.
    Methods: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility.
    Results: A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%,
    Conclusions: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.
    Language English
    Publishing date 2023-08-26
    Publishing country Switzerland
    Document type Journal Article
    ZDB-ID 2662592-1
    ISSN 2077-0383
    ISSN 2077-0383
    DOI 10.3390/jcm12175565
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  10. Article ; Online: Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact.

    Williamson, Tyler K / Dave, Pooja / Mir, Jamshaid M / Smith, Justin S / Lafage, Renaud / Line, Breton / Diebo, Bassel G / Daniels, Alan H / Gum, Jeffrey L / Protopsaltis, Themistocles S / Hamilton, D Kojo / Soroceanu, Alex / Scheer, Justin K / Eastlack, Robert / Kelly, Michael P / Nunley, Pierce / Kebaish, Khaled M / Lewis, Stephen / Lenke, Lawrence G /
    Hostin, Richard A / Gupta, Munish C / Kim, Han Jo / Ames, Christopher P / Hart, Robert A / Burton, Douglas C / Shaffrey, Christopher I / Klineberg, Eric O / Schwab, Frank J / Lafage, Virginie / Chou, Dean / Fu, Kai-Ming / Bess, Shay / Passias, Peter G

    Operative neurosurgery (Hagerstown, Md.)

    2023  Volume 26, Issue 2, Page(s) 156–164

    Abstract: Background and objectives: Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The ... ...

    Abstract Background and objectives: Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms.
    Methods: We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes.
    Results: Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE.
    Conclusion: Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.
    MeSH term(s) Adult ; Humans ; Female ; Middle Aged ; Aged ; Infant ; Male ; Lordosis/diagnostic imaging ; Lordosis/surgery ; Kyphosis/surgery ; Lower Extremity/diagnostic imaging ; Lower Extremity/surgery ; Pelvis ; Outcome Assessment, Health Care
    Language English
    Publishing date 2023-10-11
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2767575-0
    ISSN 2332-4260 ; 2332-4252
    ISSN (online) 2332-4260
    ISSN 2332-4252
    DOI 10.1227/ons.0000000000000901
    Database MEDical Literature Analysis and Retrieval System OnLINE

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