Background: Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes. Methods: We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases. Results: Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed. Conclusions: The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.

BACKGROUND: Surgical management of spine deformity is associated with significant morbidity. Recent literature has inconsistently demonstrated better outcomes after utilizing 2 attending surgeons for spine deformity. OBJECTIVE: To conduct a systematic review and meta-analysis on studies reporting outcomes following single- vs dual-attending surgeons for spine deformity. METHODS: MEDLINE, Embase, Web of science, and Cochrane databases were last searched on July 16, 2020. A total of 1013 records were identified excluding duplicates. After screening, 10 studies (4 cohort, 6 case series) were included in the meta-analysis. Random-effect models were used to pool the effect estimates by study design. When feasible, further subgroup analysis by deformity type was conducted. RESULTS: A total of 953 patients were analyzed. Pooled results from propensity score-matched cohort studies revealed that the single-surgeon approach was unfavorably associated with a nonstatistically significant higher blood loss (mean difference = 421.0 mL; 95% CI: −28.2, 870.2), a statistically significant higher operative time (mean difference = 94.3 min; 95% CI: 54.9, 133), length of stay (mean difference = 0.84 d; 95% CI: 0.46, 1.22), and an increased risk of complications (Mantel-Haenszel risk ratio = 2.93; 95% CI: 1.12, 7.66). Data from pooled case series demonstrated similar results for all outcomes. Moreover, these results did not differ significantly between deformity types (adolescent idiopathic scoliosis and adult spinal deformity). CONCLUSION: Dual-attending surgeon approach appeared to be associated with reduced operative time, shorter hospital stays, and reduced risk of complications. These findings may potentially improve outcomes in surgical treatment of spine deformity.

OBJECTIVE: Metastatic spinal cord compression (MSCC) imposes significant impairment on patient quality of life and often requires immediate surgical intervention. In this study the authors sought to estimate the impact of surgical intervention on patient quality of life in the form of mean quality-adjusted life years (QALY) gained and identify factors associated with positive outcomes.METHODS: The authors performed a retrospective chart review and collected data for patients who had neurological symptoms resulting from radiologically and histologically confirmed MSCC and were treated with surgical decompression during the last 12 years.RESULTS: A total of 151 patients were included in this study (mean age 60.4 years, 57.6% males). The 5 most common metastatic tumor types were lung, multiple myeloma, renal, breast, and prostate cancer. The majority of patients had radioresistant tumors (82.7%) and had an active primary site at presentation (67.5%). The median time from tumor diagnosis to cord compression was 12 months and the median time from identification of cord compression to death was 4 months. Preoperative presenting symptoms included motor weakness (70.8%), pain (70.1%), sensory disturbances (47.6%), and bowel or bladder disturbance (31.1%). The median estimated blood loss was 500 mL and the average length of hospital stay was 10.3 days. About 18% of patients had postoperative complications and the mean follow-up was 7 months. The mean pre- and postoperative ECOG (Eastern Cooperative Oncology Group) performance status grades were 3.2 and 2.4, respectively. At follow-up, 58.3% of patients had improved status, 31.5% had no improvement, and 10.0% had worsening of functional status. The mean QALY gained per year in the entire cohort was 0.55. The mean QALY gained in the first 6 months was 0.1 and in the first year was 0.4. For patients who lived 1–2, 2–3, 3–4, or 4–5 years, the mean QALY gained were 0.8, 1.4, 1.7, and 2.3, respectively. Preoperative motor weakness, bowel dysfunction, bladder dysfunction, and ASA (American Society of Anesthesiologists) class were identified as independent predictors inversely associated with good outcome.CONCLUSIONS: The mean QALY gained from surgical decompression in the first 6 months and first year equals 1.2 months and 5 months of life in perfect health, respectively. These findings suggest that surgery might also be beneficial to patients with life expectancy < 6 months.

Study Design. Retrospective cohort study. Objective. The primary objective of our study was to evaluate the surgical outcomes and complications of minimally invasive surgery (MIS) versus open surgery in the management of intermediate to high grade spondylolisthesis, and secondarily to compare the outcomes following MIS in-situ fusion versus MIS reduction and open in-situ fusion versus open reduction subgroups. Summary of Background Data. High-grade spondylolisthesis is a relatively rare spine pathology with unknown prevalence. The optimal management and long-term prognosis of high-grade spondylolisthesis remain controversial. Methods. A multicenter, retrospective cohort study of adult patients who were surgically treated for grade II or higher lumbar or lumbosacral spondylolisthesis from January 2008 until February 2019, was conducted. Results. A total of 57 patients were included in this study. Forty cases were treated with open surgery and 17 with MIS. Specifically, seven patients underwent MIS in-situ fusion, 11 patients open in-situ fusion, an additional 10 patients underwent MIS reduction, and 29 had open reduction. Patients who underwent open surgery had significantly better pain relief at short-term follow-up with no statistically significant difference in the rate of complications (25% vs. 35.2%, P = 0.44), as compared with MIS. The most common complications were related to instrumentation (17.7%), followed by neurological complications (14.5%), wound infection/dehiscence (6.5%), and post laminectomy syndrome (1.6%). The average follow-up time was 9.1 +/- 6.2 months. In a subgroup comparison, the complication rate in the open in-situ fusion (36.3%) versus open reduction (20.6%) subgroup was non-significant (P = 0.42). However, complication rate in the MIS reduction group (55%) was significantly higher than MIS in-situ fusion (P = 0.03). Conclusion. MIS reduction is associated with a higher rate of complications in the management of grade II or higher lumbar or lumbosacral spondylolisthesis. The management of this complex pathology may be better addressed via traditional open surgery.

Surgical intervention is a cornerstone of adult spinal deformity (ASD) management. However, there remain burdens from complications, including proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). Posterior anatomic preservation at the uppermost instrumented vertebra has emerged as an accessible approach to potentially reduce PJK/PJF risk. We assembled an institutional cohort of patients with ASD evaluated between 2017 and 2022 who had spinal fusion performed with a modified subperiosteal dissection at and immediately below the uppermost instrumented vertebra. Through a meta-analysis with a random-effects model, we compared our incidence of PJK/PJF against other prophylactic interventions. Ninety patients were identified, (median age, 64 years; average follow-up, 19 months). Most had scoliosis and/or spinal stenosis with a median of 8 levels fused (40% revision cases). 6.7% and 3.3% of patients developed PJK and PJF, respectively, with the most common clinical correlate being a minor neurologic deficit such as numbness (37.8%). PJK/PJF and non-PJK/PJF patients had similar postoperative complication profiles. Radiographic parameters varied: the PJK/PJF cohort had greater preoperative pelvic incidence/pelvic tilt and postoperative pelvic incidence-lumbar lordosis mismatch as well as smaller operative correction of the thoracolumbar Cobb angle. In the literature, prophylactic interventions broadly reduced the incidence of PJK/PJF, with a pooled estimate of 19% compared with 36% in patients who did not receive any additional intervention. Preservation of posterior anatomic structures likely has a role in reducing the rate of PJK/PJF. Linking radiographic parameters to PJK/PJF and studying techniques that keep posterior structures intact may be steps toward improving ASD correction outcomes.