39SProceedings of the NASS 27th Annual Meeting / The Spine Journal 12 (2012) 22S–44S

MD9, Justin S. Smith, MD, PhD10, Oheneba Boachie-Adjei, MD11, Eric

O. Klineberg, MD12, Douglas C. Burton, MD13, Munish C. Gupta, MD14;1Brighton, CO, US; 2Oregon Health & Science University, Portland, OR,

US; 3Southwest Scoliosis Institute, Plano, TX, US; 4NYU Langone Medical

Center, Hospital for Joint Diseases, New York, NY, US; 5New York, NY, US;6Rocky Mountain Scoliosis and Spine, Denver, CO, US; 7NYU Hospital for

Joint Diseases, New York, NY, US; 8University of California San

Francisco, San Francisco, CA, US; 9University of Virginia Department of

Neurosurgery, Charlottesville, VA, US; 10UVA Health System,

Charlottesville, VA, US; 11Hospital for Special Surgery, New York, NY, US;12UC Davis School of Medicine, Sacramento, CA, US; 13University of

Kansas Medical Center, Kansas City, KS, US; 14UC Davis Orthopaedic

Surgery, Sacramento, CA, US

BACKGROUND CONTEXT: Proximal Junctional Failure (PJF) is a po-

tentially catastrophic complication following ASD surgery. PJF is distinct

from Proximal Junctional Kyphosis, including not only increased kyphosis

but also structural failure with potential for increased pain, instability, neu-

rological injury and need for revision surgery. Risk factors for PJF remain

poorly understood.

PURPOSE: Evaluate risk factors for clinically significant PJF following

ASD surgery.

STUDY DESIGN/SETTING: Multi-center, case-control analysis of con-

secutive ASD patients suffering PJF following ASD surgery.

PATIENT SAMPLE: Consecutive ASD patients suffering PJF following

ASD surgery identified retrospectively, matched to patients without PJF

(NOPJF) from a prospective, consecutive ASD database.

OUTCOME MEASURES: Radiographic and clinical evidence of PJF,

defined as kyphosis O10� measured from upper instrumented vertebra

(UIV) to two levels above (UIVþ2), and UIV/UIVþ2 kyphosis increase

O10� from preop value, and one of the following: UIVor UIVþ1 fracture,

dislocation, or implant failure.

METHODS: Multicenter, case-control analysis of consecutive PJF pa-

tients following ASD surgery. PJF patients were matched to patients with-

out PJF (NOPJF) from a prospective ASD database according to levels

fused and UIV. Groups were divided by level of UIV into thoracolumbar

(TL; UIV5T9-T11) or upper thoracic (UT; UIV5T2-T5). All TL patients

had fusion to pelvis distally; UT patients had distal fusions to lumbar spine

or pelvis. Risk factors included: age and preop/postop sagittal vertical axis

(SVA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence mi-

nus lumbar lordosis (PI-LL), and pelvic tilt (PT). Surgical factors included

performance of pedicle subtraction osteotomy (PSO), extension to pelvis

for UT group, and need for revision surgery.

RESULTS: All PJF events occurred #7 months postop. TL group differ-

ences between PJF (n537) and NOPJF (n521) included age (59.2 vs 43.7

years), preop TK (40.5� vs 29.6�), preop LL (18.8� vs 43.6�), preop PI-LL

(35.9� vs 17.5�), and change in LL (30� vs 9.6,), respectively (p!0.05). UT

group differences between PJF (n515) and NOPJF (n533) included age

(67.8 vs 59.5 years), preop SVA (68.3 vs 1.6 mm), preop PT (26.8� vs

17.5�), preop PI-LL (19.2� vs 0.61�), preop TK (55.2� vs 33.7�), andchange in SVA (69 vs 49 mm), respectively (p!0.05). PJF was more likely

after PSO than noPSO (29% vs 6%; p!0.05) and more UT PJF patients

were fused to pelvis than NOPJF (73.3% vs 39.4%; p!0.05). Revision sur-

gery was performed more frequently for PJF than NOPJF (TL 35% vs 9%;

UT 67% vs 18%; respectively; p!0.05).

CONCLUSIONS: Case-control analysis of ASD surgical patients demon-

strated risk factors for PJF include age, sagittal deformity and sagittal cor-

rection. PSO and fusion to pelvis are also risk factors. Revision surgery is

more frequent among patients experiencing PJF, especially for UT frac-

tures. Further research is needed to identify methods to prevent PJF in

ASD patients requiring large sagittal correction.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

http://dx.doi.org/10.1016/j.spinee.2012.08.120

All referenced figures and tables will be available at the Annual Mee

77. Primary versus Revision Surgery: Multicenter Analysis of

Clinical and Functional Outcomes Following Surgery for Adult

Spinal Deformity

International Spine Study Group1Khaled M. Kebaish, MD2, Eric

O. Klineberg, MD3, Mostafa H. El Dafrawy, MD4, Christopher P. Ames,

MD5, R. Shay Bess, MD6, Vedat Deviren, MD5, Justin S. Smith, MD, PhD7,

Robert A. Hart, MD8, Richard Hostin, MD9, Michael O’Brien, MD9,

Oheneba Boachie-Adjei, MD10, Munish C. Gupta, MD11; 1Brighton, CO,

US; 2Baltimore, MD, US; 3UC Davis School of Medicine, Sacramento, CA,

US; 4Fairfax, VA, US; 5University of California San Francisco, San

Francisco, CA, US; 6Rocky Mountain Scoliosis and Spine, Denver, CO,

US; 7UVA Health System, Charlottesville, VA, US; 8Oregon Health &

Science University, Portland, OR, US; 9Southwest Scoliosis Institute,

Plano, TX, US; 10Hospital for Special Surgery, New York, NY, US; 11UC

Davis Orthopaedic Surgery, Sacramento, CA, US

BACKGROUND CONTEXT: Revision surgery for adult spinal defor-

mity (ASD) is thought to be associated with a high complication rate

and poor outcome. We hypothesize that revision deformity surgery may

have a higher incidence of complications, but patients undergoing revision

procedure experience a comparable gain in functional outcome compared

to those undergoing primary surgery.

PURPOSE: We report and compare functional outcome and complica-

tions for patients undergoing primary and revision surgery for the treat-

ment of adult spinal deformity. Despite being technically challenging,

there were similar rates of complications in both the revision and pri-

mary surgery. Both groups improved their one year HRQoL scores

and although there was greater improvement in the revision group,

the final HQRoL scores were better both pre and post operatively in

the primary group.

STUDY DESIGN/SETTING: Retrospective review of prospectively col-

lected data.

PATIENT SAMPLE: Three hundred seventeen consecutive patients with

a diagnosis of adult spinal deformity were enrolled by 8 different centers in

a prospective outcomes study. One hundred eighty-seven patients com-

pleted radiographic and clinical follow up at one year and were included

in this analysis.

OUTCOME MEASURES: Health related quality of life measures used

included Oswestry disability index, Scoliosis Research Society 22-revised

questionnaire. Radiographic assessment included full length standing sco-

liosis radiographs with detailed measurements. Clinical outcome measures

included patients’ demographics, operative data and peri-operative

complications.

METHODS: Multicenter, prospective analysis of complication rates fol-

lowing ASD surgery for consecutive ASD patients after primary surgery

(PS) or revision Surgery (RS). Inclusion criteria: age $18 yrs, ASD sur-

gery (ASD5scoliosis $20o, sagittal vertical axis (SVA) $5 cm, pelvic tilt

(PT) $25o, or thoracic kyphosis (TK)O60o), complete demographic, ra-

diographic, and operative data, and min one year follow up. Rates of major,

minor, and complications requiring surgery were evaluated. Multivariate

analysis performed.

RESULTS: Of 317 patients, 187 met inclusion criteria. 113 PS were youn-

ger (avg 53) than RS pts (avg 59) (p!0.005). Preop both groups had sim-

ilar Comorbidities and Charlson Comorbidity index (P50.13). Average

numbers of levels fused (12) was similar in both groups (p50.28) PSO per-

formed in 6 (5.3%) PS, and 23 (30.3%) RS. There was one PS mortality

and none in RS. The RS group had 22/76 (29%) with previous complica-

tions. Each group had 11 neurologic complications: (9.7%) PS compared

to (14.4%) RS (p50.359). Each group also had 17 major complications:

(15%) PS and (22%) RS (P50.246). Minor complications were also sim-

ilar: 39 (34%) PS compared to 28 (37%) RS (P50.76). However, deep

wound infections were significantly higher in the revision group (4) com-

pared to none in the primary (p50.025). Preop HRQoL scores were signif-

icantly lower for RS in all SRS domains and ODI scores (p!0.05). Both

groups had significant improvements in their functional outcome across

ting and will be included with the post-meeting online content.

40S Proceedings of the NASS 27th Annual Meeting / The Spine Journal 12 (2012) 22S–44S

SRS domains and ODI. Although RS had greater improvement across all

scores, the one year SRS scores were higher in PS except activity

(p50.11) and satisfaction (p50.07), which were similar to RS. ODI score

was lower in PS compared to RS at one year (21.5 vs 29.9, p!0.001).

CONCLUSIONS: Although more technically challenging, revision sur-

gery for ASD has similar rates of major and minor complications com-

pared to primary (except deep infection). Primary patients’ one year

ODI and SRS scores were better than revision, despite greater overall im-

provement in revision HRQoL scores.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

http://dx.doi.org/10.1016/j.spinee.2012.08.121

78. The Effect of PVCR on Pulmonary Function Improvement in

Severe Rigid Spinal Deformity Patients with Respiratory

Dysfunction

Jingming Xie, MD1, Ni Bi2, Yingsong Wang2, Ying Zhang2, Zhi Zhao, MD2,

Tao Li, MD2; 1Department of Orthopaedics, Kunming, China; 2Kunming

Medical University, Kunming, China

BACKGROUND CONTEXT: Severe rigid spinal deformity is often asso-

ciated with respiratory impairment, which increased the risk of pulmonary

complications following surgical correction. Improvement of the postoper-

ative pulmonary function was regarded by surgeons as more important cu-

rative goal than curves correction. PVCR has been reported as much

efficient for treatment of severe rigid spinal deformities, however, there

were few research involved postoperative PFT changes. Severe rigid spinal

deformity is often associated with respiratory impairment, which increased

the risk of pulmonary complications following surgical correction. Im-

provement of the postoperative pulmonary function was regarded by sur-

geons as more important curative goal than curves correction. PVCR has

been reported as much efficient for treatment of severe rigid spinal defor-

mities, however, there were few research involved postoperative PFT

changes.

PURPOSE: To determine the change in pulmonary function test (PFT)

following PVCR surgery in severe rigid spinal deformity patients with re-

spiratory dysfunction.

STUDY DESIGN/SETTING: Retrospective review.

PATIENT SAMPLE: Twenty-four PVCR patients with severe rigid spinal

deformity and obvious respiratory dysfunction from 2004 to 2009 were

enrolled.

OUTCOME MEASURES: The relationship between PFT parameters, as

well as pre- and postoperative subjective symptom improvement (respira-

tory distress, pulmonary inflammation, exercise capacity and quality of

life), and postoperative recovery period were assessed according to the

Metabolic Equivalent of Energy(MET) grade scale.

METHODS: Twenty-four PVCR patients with severe rigid spinal defor-

mity and obvious respiratory dysfunction from 2004 to 2009 were enrolled.

The mean age was 18.968.2 years (range 11-45 years). The preoperative

average scoliotic Cobb angle was 110.1�614.6� (range 94�-170�) and ky-

photic 80.6�629.2� (range 42�-160�). Patients were divided into 2 groups

according to the preoperative vital capacity (VC): moderate (40%~60%)

impairment and severe (!40%) impairment. PFT parameters were mea-

sured at preoperative, 2-weeks, 3-months, 6-months, 1-year and 2-year

postoperative, which included VC, FVC, FEV1,VC%,FVC% and FEV1.

The relationship between PFT parameters, as well as pre- and postopera-

tive subjective symptom improvement (respiratory distress, pulmonary in-

flammation, exercise capacity and quality of life), and postoperative

recovery period were assessed according to the Metabolic Equivalent of

Energy(MET) grade scale.

RESULTS: Compared to the preoperative, all involved PFT parameters

were significantly declined at 2 weeks postoperative, then gradually in-

creased to get to the preoperative baseline from 3 months to one year,

All referenced figures and tables will be available at the Annual Mee

and notable improved (VC:17.1%, FVC:18.7%, FEV1:14.4%) at 2-years

final follow up. The arterial blood gases value and MET grades has been

shown similarly recovery tendency. In addition, there were positive corre-

lation between recovery time and changes of postoperative PFT, and im-

provement in subjective symptom.

CONCLUSIONS: Patients with severe rigid spinal deformity had signif-

icant decrease in PFT parameters values at 2-week postoperative, in-

creased up to preoperative baseline at one-year postoperative, and

significantly improved at 2 years after surgery compared to the preoper-

ative. The PFT deterioration at 2-week postoperative was probably due

to prolong operative time, great amount of bleeding, pleura perforation in-

traoperation. Pulmonary function improvement following PVCR was

deemed as a process of multi-factors influenced. Enlarged thoracic cage

volume and released pulmonary alveolous following deformity correction

provided more space for ventilation. Moreover,the cardiopulmonary ves-

sel resistance was decreased, and indirectly improved Ventilation/blood

flow (VA/Q) ratio.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

http://dx.doi.org/10.1016/j.spinee.2012.08.122

79. Analysis of the Cost-Effectiveness of Surgical Treatment for

Adult Spinal Deformity

International Spine Study Group1Richard Hostin, MD2, Michael O’Brien,

MD2, Ian McCarthy, PhD3, Neil Fleming, PhD4, Gerald Ogola, MS4,

Rustam Kudyakov, MD, MPH4, Kathleen Richter, MS4, Rajiv Saigal, MD,

PhD5, Sigurd Berven, MD6, Vedat Deviren, MD5, Christopher P. Ames,

MD5; 1Brighton, CO, US; 2Southwest Scoliosis Institute, Plano, TX, US;3Baylor Health Care System, Plano, TX, US; 4Baylor University Medical

Center, Dallas, TX, US; 5University of California San Francisco, San

Francisco, CA, US; 6UCSF Department of Orthopaedic Surgery, San

Francisco, CA, US

BACKGROUND CONTEXT: In a value-based health care economy, the

cost of incremental improvement in health related quality of life (the

average cost-effectiveness ratio, or ACER) is an important consideration

for resource allocation; however, the cost-effectiveness (CE) of surgical

treatment for adult spinal deformity (ASD) has not been reported in the

literature.

PURPOSE: Analyze ACERs and respective 95% confidence intervals of

surgical treatment for patients diagnosed with one of four categories of

ASD: Primary Idiopathic Scoliosis (PIS), Primary Degenerative Scoliosis

(PDS), Primary Sagittal Plane Deformity (PSPD), and Revision (R).

STUDY DESIGN/SETTING: Multi-center, retrospective, consecutive

case series.

PATIENT SAMPLE: Three hundred twenty-three consecutive patients

undergoing surgical treatment for ASD.

OUTCOME MEASURES: HRQOL measures based on the Medical Out-

comes Study Short Form 36 (SF-36) physical and mental component

scores (PCS and MCS, respectively), the Oswestry Disability Index

(ODI), and the Scoliosis Research Society (SRS functional activity, pain,

self-image, and mental health scores) questionnaires after at least one year

following surgery. SRS scores were translated to a 100 point scale. Costs

were collected from hospital data and included direct costs (DC) incurred

for the episode of surgical care.

METHODS: Patients ranged from 18 to 85 years of age, with an average

age of 54. Patients were assigned to one of four diagnostic categories based

on pre-operative radiographs and history: PDS (n559, 18%), PIS (n5102,

32%), PSPD (n539, 12%), and R (n5123, 38%). ACERs were estimated

as the ratio of DC to HRQOL improvements, and confidence intervals were

calculated using nonparametric bootstrap methods.

RESULTS: For all categories of ASD, statistical analysis provided point es-

timates and 95% confidence intervals for the following HRQOL measures:

ting and will be included with the post-meeting online content.