According to a National Institutes of Health (NIH) study, adult spinal deformity develops in as many as 68% of healthy adults over the age of 651. With that in mind, a multicenter team set out to establish standardized values for the rates of complications by type of surgery performed. Their work, “Benchmark Values for Construct Survival and Complications by Type of ASD Surgery,” was published in the September 2024 edition of Spine.
“Adult spinal deformity encompasses a broad spectrum of presentations, each requiring varying surgical strategies,” co-author Virginie Lafage, Ph.D., told OTW.
Dr. Lafage, associate VP of Clinical Research at Lenox Hill Hospital | Northwell Health in New York City, explained the genesis of this study to OTW, “Our interest stemmed from a desire to understand the proportion of patients treated with the approaches commonly associated with adult spinal deformity, the complication rates linked to each major surgical strategy, and the timing of these complications. Surprisingly, it is challenging to find clear and detailed benchmark values for adult spinal deformity treatment. We aimed to contribute to the field by providing this essential information.”
To tease out these values, the research team collected patient data from a 20-center North American Adult Spinal Deformity database and organized that data into the following patient diagnostic categories:
scoliosis ≥20°,
sagittal vertical axis (SVA) ≥ 5 cm,
pelvic tilt (PT) ≥ 25°, or
thoracic kyphosis ≥ 60°.”
The team then categorized the surgical treatment type according to:
upon the number of levels treated,
positions of the upper and lower instrumented vertebrae,
use of three-column osteotomy, and
presence of previous spinal fusion.
Using these categorization criteria generated eight distinct surgical scenarios:
short lumbar,
thoracic to lumbar,
upper thoracic to pelvis (with three-column osteotomy, primary, and revision subtypes), and
lower thoracic to pelvis (with three-column osteotomy, primary, and revision subtypes).
As for what is it about the relationship between type of surgery and construct survival that is challenging to capture, Dr. Lafage told OTW, “Analyzing the relationship between construct type and survival is challenging because the construct is only one of many factors influencing outcomes. Patient characteristics play a significant role. For instance, comorbidities such as osteoporosis—common in this population—can greatly impact results. Past medical history (e.g., prior infections) and the specifics of the surgical correction (e.g., overcorrection or under correction, implant malposition) also contribute to both early and long-term outcomes.”
“Construct type is, arguably, the easiest variable to standardize and study. However, it was not feasible to account for every factor affecting outcomes. First, many such factors exist, and some may remain unidentified. Second, controlling for all variables would require a much larger sample size. Instead, our goal was to provide a benchmark analysis, adjusting for select patient characteristics, to help providers estimate the ‘normal’ course of Adult Spinal Deformity treatment outcomes from a statistical perspective.”
Study Results
The team was able to collect data from 1,073 patients. After analyzing the data, the team determined that survival curves for major complications (with or without reoperation), while controlling for demographics, differed significantly among surgical types.
Specifically, fusion procedures short of the pelvis had the best survival rate, while upper thoracic-pelvis with three-column osteotomy had the worst survival rate. Longer fusions and more invasive operations were associated with lower two-year complication-free survival, however, there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition, or neurological complications.
“The results were largely as expected: longer and more invasive surgeries are associated with higher complication rates. We had hoped to identify a particular surgical approach that performed significantly better, but the findings align with existing literature and our understanding of this complex treatment.”
“What stood out was the behavior beyond the first 100 days post-surgery. It appears that trajectories of outcomes remain relatively parallel for the first two years. It will be fascinating to revisit this analysis with longer-term data (e.g., at 5- or 10-year follow-ups) to explore how these trajectories evolve.”
“Complications and, ultimately, revision surgeries are an inherent part of adult spinal deformity treatment. We want surgeons to have realistic expectations for construct survival across different surgical strategies, enabling them to counsel patients more effectively about the risks associated with these procedures. From a health economics perspective, understanding expected survival is also critical for designing appropriate bundled payment models. We hope our findings provide a foundation for both clinical decision-making and economic planning in adult spinal deformity care.”
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