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Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes.

Publication ,  Journal Article
Daniels, AH; Reid, DBC; Durand, WM; Hamilton, DK; Passias, PG; Kim, HJ; Protopsaltis, TS; Lafage, V; Smith, JS; Shaffrey, CI; Gupta, M ...
Published in: J Neurosurg Spine
December 20, 2019

OBJECTIVE: Optimal patient selection for upper-thoracic (UT) versus lower-thoracic (LT) fusion during adult spinal deformity (ASD) correction is challenging. Radiographic and clinical outcomes following UT versus LT fusion remain incompletely understood. The purposes of this study were: 1) to evaluate demographic, radiographic, and surgical characteristics associated with choice of UT versus LT fusion endpoint; and 2) to evaluate differences in radiographic, clinical, and health-related quality of life (HRQOL) outcomes following UT versus LT fusion for ASD. METHODS: Retrospective review of a prospectively collected multicenter ASD database was performed. Patients with ASD who underwent fusion from the sacrum/ilium to the LT (T9-L1) or UT (T1-6) spine were compared for demographic, radiographic, and surgical characteristics. Outcomes including proximal junctional kyphosis (PJK), reoperation, rod fracture, pseudarthrosis, overall complications, 2-year change in alignment parameters, and 2-year HRQOL metrics (Lumbar Stiffness Disability Index, Scoliosis Research Society-22r questionnaire, Oswestry Disability Index) were compared after controlling for confounding factors via multivariate analysis. RESULTS: Three hundred three patients (169 LT, 134 UT) were evaluated. Independent predictors of UT fusion included greater thoracic kyphosis (odds ratio [OR] 0.97 per degree, p = 0.0098), greater coronal Cobb angle (OR 1.06 per degree, p < 0.0001), and performance of a 3-column osteotomy (3-CO; OR 2.39, p = 0.0351). While associated with longer operative times (ratio 1.13, p < 0.0001) and greater estimated blood loss (ratio 1.31, p = 0.0018), UT fusions resulted in greater sagittal vertical axis improvement (-59.5 vs -41.0 mm, p = 0.0035) and lower PJK rates (OR 0.49, p = 0.0457). No significant differences in postoperative HRQOL measures, reoperation, or overall complication rates were detected between groups (all p > 0.1). CONCLUSIONS: Greater deformity and need for 3-CO increased the likelihood of UT fusion. Despite longer operative times and greater blood loss, UT fusions resulted in better sagittal correction and lower 2-year PJK rates following surgery for ASD. While continued surveillance is necessary, this information may inform patient counseling and surgical decision-making.

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Published In

J Neurosurg Spine

DOI

EISSN

1547-5646

Publication Date

December 20, 2019

Start / End Page

1 / 7

Location

United States

Related Subject Headings

  • Orthopedics
  • 3209 Neurosciences
  • 1109 Neurosciences
  • 1103 Clinical Sciences
 

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Daniels, A. H., Reid, D. B. C., Durand, W. M., Hamilton, D. K., Passias, P. G., Kim, H. J., … International Spine Study Group, . (2019). Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes. J Neurosurg Spine, 1–7. https://doi.org/10.3171/2019.9.SPINE19557
Daniels, Alan H., Daniel B. C. Reid, Wesley M. Durand, D Kojo Hamilton, Peter G. Passias, Han Jo Kim, Themistocles S. Protopsaltis, et al. “Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes.J Neurosurg Spine, December 20, 2019, 1–7. https://doi.org/10.3171/2019.9.SPINE19557.
Daniels AH, Reid DBC, Durand WM, Hamilton DK, Passias PG, Kim HJ, Protopsaltis TS, Lafage V, Smith JS, Shaffrey CI, Gupta M, Klineberg E, Schwab F, Burton D, Bess S, Ames CP, Hart RA, International Spine Study Group. Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes. J Neurosurg Spine. 2019 Dec 20;1–7.

Published In

J Neurosurg Spine

DOI

EISSN

1547-5646

Publication Date

December 20, 2019

Start / End Page

1 / 7

Location

United States

Related Subject Headings

  • Orthopedics
  • 3209 Neurosciences
  • 1109 Neurosciences
  • 1103 Clinical Sciences