The Incremental Clinical Benefit of Adding Layers of Complexity to the Planning and Execution of Adult Spinal Deformity Corrective Surgery

Katherine E Pierce; Jamshaid M Mir; Pooja Dave; Renaud Lafage; Virginie Lafage; Paul Park; Pierce Nunley; Gregory Mundis; Jeffrey Gum; Peter Tretiakov; Juan Uribe; Richard Hostin; Robert Eastlack; Bassel Diebo; Han Jo Kim; Justin S Smith; Christopher P Ames; Christopher Shaffrey; Douglas Burton; Robert Hart; Shay Bess; Eric Klineberg; Frank Schwab; Munish Gupta; D Kojo Hamilton; Peter G Passias; International Spine Study Group

doi:10.1227/ons.0000000000001192

The Incremental Clinical Benefit of Adding Layers of Complexity to the Planning and Execution of Adult Spinal Deformity Corrective Surgery

Oper Neurosurg (Hagerstown). 2024 May 21. doi: 10.1227/ons.0000000000001192. Online ahead of print.

Authors

Katherine E Pierce¹, Jamshaid M Mir¹, Pooja Dave¹, Renaud Lafage², Virginie Lafage², Paul Park³, Pierce Nunley⁴, Gregory Mundis⁵, Jeffrey Gum⁶, Peter Tretiakov¹, Juan Uribe⁷, Richard Hostin⁸, Robert Eastlack⁹, Bassel Diebo¹⁰, Han Jo Kim², Justin S Smith¹¹, Christopher P Ames¹², Christopher Shaffrey¹³, Douglas Burton¹⁴, Robert Hart¹⁵, Shay Bess¹⁶, Eric Klineberg¹⁷, Frank Schwab², Munish Gupta¹⁸, D Kojo Hamilton¹⁹, Peter G Passias¹; International Spine Study Group

Affiliations

¹ Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA.
² Department of Orthopedic, Lenox Hill Hospital, Northwell, New York, New York, USA.
³ Department of Neurologic Surgery, University of Michigan, Ann Arbor, Michigan, USA.
⁴ Spine Institute of Louisiana, Shreveport, Louisiana, USA.
⁵ San Diego Center for Spinal Disorders, La Jolla, California, USA.
⁶ Norton Leatherman Spine Center, Louisville, Kentucky, USA.
⁷ Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
⁸ Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA.
⁹ Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA.
¹⁰ Department of Orthopedic Surgery, SUNY Downstate, New York, New York, USA.
¹¹ Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
¹² Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
¹³ Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
¹⁴ Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA.
¹⁵ Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA.
¹⁶ Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA.
¹⁷ Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA.
¹⁸ Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA.
¹⁹ Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

PMID: 38771063
DOI: 10.1227/ons.0000000000001192

Abstract

Background and objectives: For patients with surgical adult spinal deformity (ASD), our understanding of alignment has evolved, especially in the last 20 years. Determination of optimal restoration of alignment and spinal shape has been increasingly studied, yet the assessment of how these alignment schematics have incrementally added benefit to outcomes remains to be evaluated.

Methods: Patients with ASD with baseline and 2-year were included, classified by 4 alignment measures: Scoliosis Research Society (SRS)-Schwab, Age-Adjusted, Roussouly, and Global Alignment and Proportion (GAP). The incremental benefits of alignment schemas were assessed in chronological order as our understanding of optimal alignment progressed. Alignment was considered improved from baseline based on SRS-Schwab 0 or decrease in severity, Age-Adjusted ideal match, Roussouly current (based on sacral slope) matching theoretical (pelvic incidence-based), and decrease in proportion. Patients separated into 4 first improving in SRS-Schwab at 2-year, second Schwab improvement and matching Age-Adjusted, third two prior with Roussouly, and fourth improvement in all four. Comparison was accomplished with means comparison tests and χ2 analyses.

Results: Sevenhundredthirty-two. patients met inclusion. SRS-Schwab BL: pelvic incidence-lumbar lordosis mismatch (++:32.9%), sagittal vertical axis (++: 23%), pelvic tilt (++:24.6%). 640 (87.4%) met criteria for first, 517 (70.6%) second, 176 (24%) third, and 55 (7.5%) fourth. The addition of Roussouly (third) resulted in lower rates of mechanical complications and proximal junctional kyphosis (48.3%) and higher rates of meeting minimal clinically important difference (MCID) for physical component summary and SRS-Mental (P < .05) compared with the second. Fourth compared with the third had higher rates of MCID for ODI (44.2% vs third: 28.3%, P = .011) and SRS-Appearance (70.6% vs 44.8%, P < .001). Mechanical complications and proximal junctional kyphosis were lower with the addition of Roussouly (P = .024), while the addition of GAP had higher rates of meeting MCID for SRS-22 Appearance (P = .002) and Oswestry Disability Index (P = .085).

Conclusion: Our evaluation of the incremental benefit that alignment schemas have provided in ASD corrective surgery suggests that the addition of Roussouly provided the greatest reduction in mechanical complications, while the incorporation of GAP provided the most significant improvement in patient-reported outcomes.