Cause and Effect of Revision Surgery: A Multicenter Study on Outcomes after Recurrent Adult Spinal Deformity Surgery as a function of Etiology

Thursday, June 1, 2023

8:30 AM – 6:15 PM

Presenting Author (Person doing the Podium Present(s)

PP

Peter G. Passias, M.D.

Spine Surgeon
NYU Langone Orthopedic Hospital
New York, New York, United States

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Co-Author(s)

PD

Pooja R. Dave

Miami, Florida, United States
JS

Justin Smith, MD, PhD

University of Virginia
Charlottesville, Virginia, United States
Virginie Lafage, PhD

AVP, Clinical Research
Lenox Hill | Northwell
Hospital for Special Surgery
New York, New York, United States
PT

Peter S. Tretiakov, BS

United States
JM

Jamshaid M. Mir, MD

Research Fellow
NYU Langone Health | NY Spine Institute, United States
BL

Breton Line, BS

Research Assistant
Denver International Spine Center
Denver, Colorado, United States
JD

Jennifer De Jong

United States
BD

Bassel Diebo, MD

Spine Surgeon
Brown University
Brooklyn, Rhode Island, United States
AD

Alan H. Daniels, MD

Chief, Spine Surgery
Brown University
East Providence, RI, United States
JG

Jeffrey L. Gum, MD

Adult and Pediatric Spine Surgeon
Norton Leatherman Spine
Louisville, Kentucky, United States
TP

Themistocles S. Protopsaltis, MD

Chief, Division of Spine Surgery
NYU Langone Health Department of Orthopedic Surgery
New York, New York, United States
DH

D Kojo Hamilton, MD

Associate Professor
University of Pittsburgh
Pittsburgh, Pennsylvania, United States
AS

Alex Soroceanu, MD

Clinical Associate Professor
University of Calgary
Calgary, Alberta, United States
JS

Justin Scheer

NYU Langone Orthopedic Hospital
NY, New York, United States
Robert K. Eastlack, M.D.

Partner, Spine Section, Division of Orthopaedic Surgery
Scripps Clinic
La Jolla, California, United States
JM

Jeffrey Mullin

United States
Gregory M. Mundis, Jr., M.D.

Director San Diego Spine Fellowship
Scripps Clinic
Encinitas, California, United States
NH

Naobumi Hosogane

United States
MY

Mitsuru Yagi

United States
MK

Michael Kelly

Washington University, School of Medicine
St. Louis, Missouri, United States
JU

Juan S. Uribe, M.D.

Chief of Spinal Disorders
Barrow Neurological Institute
phoenix, Arizona, United States
NA

Neel Anand, MD

Medical Director: Spine Center
Cedars Sinai Medical Center
Los Angeles, California, United States
PM

Praveen V. Mummaneni, MD, MBA

Professor
University of California San Francisco
san francisco, California, United States
DC

Dean Chou, MD

Columbia University, United States
EK

Eric Klineberg, MD

Professor/ Vice Chair Dept or Orthopaedic Surgery
University of CA, Davis
Sacramento, California, United States
KK

Khaled M. Kebaish

Johns Hopkins University, Maryland, United States
SL

Stephen Lewis

United States
MG

Munish C. Gupta, MD

M. B. Simon Distinguished Professor of Orthopaedic Surgery, Professor of Neurological Surgery
Washington University School of Medicine, St. Louis, USA
St. Louis, Missouri, United States
HK

Han Jo Kim, MD

Associate Professor
Hospital for Special Surgery
New York, NY, United States
RH

Robert A. Hart, MD

Surgeon
Swedish Neuroscience Institute
Seattle, WA, United States
LL

Larry Lenke

United States
CA

Christopher Ames

United States
CS

Christopher I. Shaffrey, Sr., MD

Duke University Medical Center
Durham, North Carolina, United States
FS

Frank Schwab, MD

Lenox Hill Hospital, Northwell Health
New York, New York, United States
RL

Renaud Lafage, MS

Senior Biomedical engineer
Lenox Hill Hospital
new york, New York, United States
RH

Richard Hostin, MD

Medical Director
Southwest Scoliosis Institute
Plano, Texas, United States
SB

Shay Bess, M.D.

Spine surgeon
Denver International Spine Center
castle rock, Colorado, United States
DB

Douglas Burton, MD

Department Chair, Orthopedic Surgery and Sports Medicine
University of Kansas Medical Center
Kansas City, Kansas, United States

Submitter(s)

PP

Peter G. Passias, M.D.

Spine Surgeon
NYU Langone Orthopedic Hospital
New York, New York, United States

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Disclosure(s):

Peter G. Passias, M.D.: No relevant disclosure to display

Robert K. Eastlack, M.D.: No relevant disclosure to display

Background: While treatment of adult spinal deformity (ASD) has increasingly favored surgical correction, incidence of revision surgery remains high. Yet, there has been little exploration on association between etiology of reoperation and its differences in recovery process.

Purpose: To assess impact of etiology of revision surgery on postoperative outcomes

Methods: Operative ASD patients ≥ 1 revisions stratified by etiology (mechanical [M] – pseudoarthrosis, thoracic decompensation without junctional failure, x-ray malalignment, implant failure, implant malposition, PJK +/- major malalignment; infection [I]– early vs late onset, major vs minor; wound [W]; SI pain [P]). Excluded multiple etiologies, and intraoperative or medical complications. Data from immediate visit prior to final revision used as baseline (rBL). Follow-up based on visits best aligned to time points after final revision. Radiographic parameters SVA, PI-LL, and PT were used to assess alignment post-revision via ANOVA. Multivariate analysis controlling for relevant covariates assessed differences in outcomes after final revision surgery.

Results: 891 met inclusion (Age: 60.40±14.17, 77% F, BMI: 27.97±5.87 kg/m2, CCI: 1.80±1.73). Etiology groups were as follows: M: 432; I: 296; W: 65; P: 98. Surgically, I had lower rates of osteotomy, interbody fusion, and decompression (p <.05). I and P demonstrated similar correction in radiographics SVA, PI-LL, and PT (p>.05), whereas M had significantly less improvement by 2 years (p <.003) that improved by 5 years. Compared to without revision, odds of MCID in ODI were 48.6% lower across groups (OR: 0.514 [.280, .945], p=.032). Indication of x-ray malalignment were 93.0% less likely to reach MCID (OR: 0.071, [.006, .866], p=.038). Similarly, implant failure negatively impacted rates of MCID (40% vs. 15.2%, p=.029). Those with PJK had 57% lower odds of MCID (33% vs 54%, OR: .43, [0.2, 0.9] p= 0.023), further negated by major malalignment (OR: 0.05, [.07, .97], p=.02). Indications of pseudoarthrosis, thoracic decompensation, implant malposition were not significant. Major sepsis had lower rates of MCID compared to minor (6.4% vs. 21.2%), and early onset infection improved compared to late (OR: 1.43, [1.17, 2.98], p<.001). In early follow up period, M group has significantly worse SRS Pain and Mental Health scores compared to other groups (1-year: M 1.56 vs I 0.83 vs P 0.72, p< 0.001; 2-year: 1.88 vs 0.71 vs 0.76, p=0.034). Complication rates increased with number of revisions and with mechanical indication (all p<.05). At 5 years, patient satisfaction was significantly more likely to improve compared to early follow up (OR: 1.22, p=.011), along with improved pain score, in M group (0.89 vs 0.49 vs 0.56, p=.081).

Conclusions: This study focused on impact of revision as it varies with etiology and time of occurrence postoperatively. Compared to other etiologies, patients revisiting surgery due to mechanical complications had less radiographic improvement and worsening patient-reported scores in early postoperative period, despite stabilization at 5 years. The depth of impact of mechanical complication, particularly with addition of malalignment, merit greater focus during surgical planning