Recovery kinetics following spinal deformity correction

a comparison of isolated cervical, thoracolumbar, and combined deformity morphometries

International Spine Study Group

Research output: Contribution to journalArticle

Abstract

BACKGROUND CONTEXT: The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a “good” versus a “bad” postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations. PURPOSE: To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology. STUDY DESIGN/SETTING: Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases. PATIENT SAMPLE: One hundred seventy spinal deformity patients. OUTCOME MEASURES: Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points. METHODS: Operative deformity patients >18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups. RESULTS: One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p >. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p =.020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p =.028). NRS Back pain differences between groups subsided by 2-years (p>.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p <.001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p <.001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p =.060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p =.004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p =.039) and osteoporosis (adjusted beta: 0.269, p =.007) as the strongest predictors of a poor NRS back IHS (model summary: R 2 = 0.177, p =.039). CONCLUSIONS: Despite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.

Original languageEnglish (US)
JournalSpine Journal
DOIs
StatePublished - Jan 1 2019

Fingerprint

Quality of Life
Back Pain
Neck
Linear Models
Health
Osteoporosis
Area Under Curve
Kyphosis
Databases
Benchmarking
Pain Measurement
Postoperative Pain
Comorbidity
Smoking
Depression
Minimal Clinically Important Difference

Keywords

  • Adult spine deformity
  • Cervical deformity
  • Distal junctional kyphosis
  • HRQOL
  • Proximal junctional kyphosis
  • Recovery kinetics

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine
  • Clinical Neurology

Cite this

@article{d40e203f91e94a82a3d5b6db85593a6f,
title = "Recovery kinetics following spinal deformity correction: a comparison of isolated cervical, thoracolumbar, and combined deformity morphometries",
abstract = "BACKGROUND CONTEXT: The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a “good” versus a “bad” postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations. PURPOSE: To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology. STUDY DESIGN/SETTING: Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases. PATIENT SAMPLE: One hundred seventy spinal deformity patients. OUTCOME MEASURES: Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points. METHODS: Operative deformity patients >18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups. RESULTS: One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p >. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p =.020). Posterior surgical approaches were most common (62.9{\%}) followed by combined (28.8{\%}) and anterior (6.5{\%}). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p =.028). NRS Back pain differences between groups subsided by 2-years (p>.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3{\%} vs. 0{\%} vs. 23.0{\%}, p <.001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9{\%} vs. 59.3{\%} vs. 62.9{\%}, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p <.001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p =.060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p =.004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p =.039) and osteoporosis (adjusted beta: 0.269, p =.007) as the strongest predictors of a poor NRS back IHS (model summary: R 2 = 0.177, p =.039). CONCLUSIONS: Despite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.",
keywords = "Adult spine deformity, Cervical deformity, Distal junctional kyphosis, HRQOL, Proximal junctional kyphosis, Recovery kinetics",
author = "{International Spine Study Group} and Passias, {Peter G.} and Segreto, {Frank A.} and Renaud Lafage and Virginie Lafage and Smith, {Justin S.} and Line, {Breton G.} and Scheer, {Justin K.} and Mundis, {Gregory M.} and Hamilton, {D. Kojo} and Kim, {Han Jo} and Horn, {Samantha R.} and Bortz, {Cole A.} and Diebo, {Bassel G.} and Shaleen Vira and Gupta, {Munish C.} and Klineberg, {Eric O.} and Burton, {Douglas C.} and Robert Hart and Schwab, {Frank J.} and Shaffrey, {Christopher I.} and Ames, {Christopher P.} and Shay Bess",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.spinee.2019.03.006",
language = "English (US)",
journal = "Spine Journal",
issn = "1529-9430",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Recovery kinetics following spinal deformity correction

T2 - a comparison of isolated cervical, thoracolumbar, and combined deformity morphometries

AU - International Spine Study Group

AU - Passias, Peter G.

AU - Segreto, Frank A.

AU - Lafage, Renaud

AU - Lafage, Virginie

AU - Smith, Justin S.

AU - Line, Breton G.

AU - Scheer, Justin K.

AU - Mundis, Gregory M.

AU - Hamilton, D. Kojo

AU - Kim, Han Jo

AU - Horn, Samantha R.

AU - Bortz, Cole A.

AU - Diebo, Bassel G.

AU - Vira, Shaleen

AU - Gupta, Munish C.

AU - Klineberg, Eric O.

AU - Burton, Douglas C.

AU - Hart, Robert

AU - Schwab, Frank J.

AU - Shaffrey, Christopher I.

AU - Ames, Christopher P.

AU - Bess, Shay

PY - 2019/1/1

Y1 - 2019/1/1

N2 - BACKGROUND CONTEXT: The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a “good” versus a “bad” postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations. PURPOSE: To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology. STUDY DESIGN/SETTING: Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases. PATIENT SAMPLE: One hundred seventy spinal deformity patients. OUTCOME MEASURES: Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points. METHODS: Operative deformity patients >18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups. RESULTS: One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p >. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p =.020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p =.028). NRS Back pain differences between groups subsided by 2-years (p>.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p <.001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p <.001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p =.060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p =.004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p =.039) and osteoporosis (adjusted beta: 0.269, p =.007) as the strongest predictors of a poor NRS back IHS (model summary: R 2 = 0.177, p =.039). CONCLUSIONS: Despite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.

AB - BACKGROUND CONTEXT: The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a “good” versus a “bad” postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations. PURPOSE: To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology. STUDY DESIGN/SETTING: Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases. PATIENT SAMPLE: One hundred seventy spinal deformity patients. OUTCOME MEASURES: Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points. METHODS: Operative deformity patients >18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups. RESULTS: One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p >. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p =.020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p =.028). NRS Back pain differences between groups subsided by 2-years (p>.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p <.001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p <.001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p =.060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p =.004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p =.039) and osteoporosis (adjusted beta: 0.269, p =.007) as the strongest predictors of a poor NRS back IHS (model summary: R 2 = 0.177, p =.039). CONCLUSIONS: Despite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.

KW - Adult spine deformity

KW - Cervical deformity

KW - Distal junctional kyphosis

KW - HRQOL

KW - Proximal junctional kyphosis

KW - Recovery kinetics

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U2 - 10.1016/j.spinee.2019.03.006

DO - 10.1016/j.spinee.2019.03.006

M3 - Article

JO - Spine Journal

JF - Spine Journal

SN - 1529-9430

ER -