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P28. Bone mineral density t-score is an independent predictor of significant blood loss in adult spinal deformity surgery
Proceedings of the 34th Annual Meeting of the North American Spine Society / The Spine Journal 19 (2019) S158−S194 STUDY DESIGN/SETTING: Retrospective review of a prospective multicenter database of ASD patients. PATIENT SAMPLE: A total of 296 surgical ASD patients who were using opioids (daily or weekly) prior to surgical intervention. OUTCOME MEASURES: Post-operative opioid cessation or decreased use, HRQOL (SF-36, ODI, back pain, leg pain), and patient satisfaction. METHODS: A multicenter prospective database of surgical ASD patients was reviewed. Opioid use was measured using the SRS-22r Q11. We included all surgical ASD patients who using opioids preoperatively (daily or weekly) and completed 2-year follow up. Patients were divided based on 2-year opioid use: decreased/ceased vs continued. Groups were compared in regards to demographics, radiographic parameters, HRQL, invasiveness of surgery, complications, re-operations, and satisfaction. RESULTS: Our database had a total of 1,281 surgical patients, out of which 760 were eligible for 2-year follow up. Of those eligible, 578 (76.05%) completed their 2-year follow up. A total of 547 of these patients answered SRS22R-Q11 at baseline at 2-years (with the remainder choosing to not answer this question). There were 296 (54.11%) of 547 ASD patients undergoing surgery reported using opioids preoperatively. Of those, 171 (57.8%) had decreased or ceased opioids 2 years after surgical intervention. Those who decreased/ceased had a higher proportion of females (83.83% vs 72.00%, p=0.014). There was no other statistically significant difference in demographics (BMI, co-morbidities, age, prior spine surgery, smoking) or radiographic parameters (PI-LL, SVA, PT). Those who decreased/ceased opioids had higher baseline SF-36 MCS − vitality (38.31 vs 35.69, p=0.03), with no difference in the remainder of the baseline HRQL scores (back and leg pain, ODI, SF-36 PCS). There were less 3COs performed in those who decreased/ceased (13.45% vs 25.60%, p=0.013). The groups had similar major complications and re-operations, and similar postop radiographic parameters. Patients that reduced/ceased had significantly better HRQL scores 2 years post operatively: back NSR (3.47 vs 5.3, p=0.0001), leg NSR (2.7 vs 3.95, p=0.0006), SF-36 MCS (50.61 vs 44.62, p=0.0002), SF-36 PCS (39.98vs 31.19, p=0.0001), and ODI (27.9 vs 44.62, p=0.0001). They were more likely to reach MCID (ODI 68.64% vs 27.42%, PCS 75.47% vs 39.17% p=0.0001) and be satisfied with surgery (84.7% vs 71.3%, p=0.003). CONCLUSIONS: In ASD patients using opioids pre-operatively, only 57.8% will decrease or cease use at 2-years despite similar correction, complications and reoperations. Those who decrease or cease post op have better HRQL scores and are more satisfied with surgery. Future research should focus on identifying those at risk of continued opioid use and developing strategies for successfully tapering. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.451
P28. Bone mineral density t-score is an independent predictor of significant blood loss in adult spinal deformity surgery Andrew B. Harris, BS1, Varun Puvanesarajah, MD2, Micheal Raad, MD3, Corinna Zygourakis, MD4, A. Jay Khanna, MD5, Khaled M. Kebaish, MD6; 1 Johns Hopkins Hospital, Baltimore, MD, US; 2 Johns Hopkins Medicine, Baltimore, MD, US; 3 Baltimore, MD, US; 4 Stanford Dept of Neurosurgery, Stanford, CA, US; 5 Johns Hopkins Orthopaedic Surgery− National Capital Region, Bethesda, MD, US; 6 Johns Hopkins University, Baltimore, MD, US BACKGROUND CONTEXT: Blood loss is an important cause of morbidity in Adult Spinal Deformity (ASD) surgery. Thus, identifying potentially modifiable factors associated with increased EBL in ASD surgery is important. Bone mineral density (BMD), as measured by Dual-energy Xray Absorptiometry (DEXA), is important for stable instrumented fixation and is often measured preoperatively in ASD patients. However, the association between BMD and intraoperative blood loss in ASD patients has not been studied.
S171
PURPOSE: Lower BMD is associated with greater odds of major blood loss in ASD surgery. STUDY DESIGN/SETTING: Cross-sectional study from a single surgeon at an academic institution. PATIENT SAMPLE: A total of 91 ASD patients (>5 levels fused) who had preoperative DEXA score recorded within the year preceeding surgery. OUTCOME MEASURES: Our primary outcome was major blood loss, defined as >2L of estimated blood loss, using the upper 90th percentile of our study population. METHODS: The lowest preoperative T-score was recorded. Patients were excluded who had liver/kidney disease or were on prescription anticoagulant medication. Binomial regression was performed controlling for age, number of vertebra fused, 3-column osteotomy, primary vs. revision surgery, preoperative platelet count, and if the patient was taking medication for osteoporosis. Significance was set at p=0.05. RESULTS: Mean age of patients was 63 § 11.6 years, 81% female. 56 (62%) of cases included revision of previous instrumentation. Patients had a mean SVA of 9.6 § 8.6cm and median of 9 vertebra fused (range 5-22). The average T-score was -1.2 § 1.0. Each point lower T-score was associated with significantly higher odds of major blood loss (OR 2.5, 95% CI 1.0 − 5.9) when controlling for age, number of vertebra fused, 3-column osteotomy, preoperative platelet count and primary vs. revision surgery. CONCLUSIONS: Lower preoperative T-score is independently associated with increased odds of significant blood loss in ASD surgery. Surgeons should anticipate increased blood loss in ASD patients with lower bone mineral density. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.452
P29. Caudally directed upper-instrumented vertebra pedicle screws minimize the risk of proximal junctional failure in patients with long posterior spinal fusion for adult spinal deformity Andrew B. Harris, BS1, Floreana K. Naef, MD2, Varun Puvanesarajah, MD3, Micheal Raad, MD4, Matthew W. Wilkening, MD5, David B. Cohen, MD, MPH2, Brian J. Neuman, MD4, Khaled M. Kebaish, MD2; 1 Johns Hopkins Hospital, Baltimore, MD, US; 2 Johns Hopkins University, Baltimore, MD, US; 3 Johns Hopkins Medicine, Baltimore, MD, US; 4 Baltimore, MD, US; 5 Belmont, MI, US BACKGROUND CONTEXT: Proximal junctional kyphosis (PJK) and Proximal Junctional Failure (PJF) are significant complications following Adult Spinal Deformity (ASD) surgery. Orientation of the Upper Instrumented Vertebra (UIV) pedicle screw has not been studied as a potential risk factor for PJK/PJF. PURPOSE: To demonstrate the association between UIV pedicle screw cranial-caudal trajectory and the development of both PJK and PJF in ASD patients with thoracolumbar fusion to the pelvis. STUDY DESIGN/SETTING: Retrospective case series. PATIENT SAMPLE: A total of 96 ASD patients (>5 levels fused) were identified from a multiprovider academic institution with fusion from T8T12 to pelvis and 2-year follow-up. OUTCOME MEASURES: Our primary outcomes were the development of PJK, defined as a proximal junction sagittal Cobb angle ≥10˚ and proximal junction sagittal Cobb angle ≥10˚ higher than preoperative measurement; and PJF, defined as revision surgery for PJK. METHODS: We defined a novel measurement of the UIV Screw Angle (UIVSA) as the mean of the angles between the UIV superior endplate and each UIV pedicle screw using intraoperative sagittal radiographs. A screw pointed cranially was measured as (+) UIVSA and a screw pointed caudally was measured as (-)UIVSA. A threshold UIVSA of +3˚ was determined by the maximum likelihood of PJK using the area under a Receiver Operating Curve. Using binary logistic regression, we examined the development of PJK and PJF in patients with UIVSA above and below +3˚, while controlling for preoperative TK, osteoporosis and age.
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.
P28. Bone mineral density t-score is an independent predictor of significant blood loss in adult spinal deformity surgery Andrew B. Harris, BS1, Varun Puvanesarajah, MD2, Micheal Raad, MD3, Corinna Zygourakis, MD4, A. Jay Khanna, MD5, Khaled M. Kebaish, MD6; 1 Johns Hopkins Hospital, Baltimore, MD, US; 2 Johns Hopkins Medicine, Baltimore, MD, US; 3 Baltimore, MD, US; 4 Stanford Dept of Neurosurgery, Stanford, CA, US; 5 Johns Hopkins Orthopaedic Surgery− National Capital Region, Bethesda, MD, US; 6 Johns Hopkins University, Baltimore, MD, US BACKGROUND CONTEXT: Blood loss is an important cause of morbidity in Adult Spinal Deformity (ASD) surgery. Thus, identifying potentially modifiable factors associated with increased EBL in ASD surgery is important. Bone mineral density (BMD), as measured by Dual-energy Xray Absorptiometry (DEXA), is important for stable instrumented fixation and is often measured preoperatively in ASD patients. However, the association between BMD and intraoperative blood loss in ASD patients has not been studied.
S171
PURPOSE: Lower BMD is associated with greater odds of major blood loss in ASD surgery. STUDY DESIGN/SETTING: Cross-sectional study from a single surgeon at an academic institution. PATIENT SAMPLE: A total of 91 ASD patients (>5 levels fused) who had preoperative DEXA score recorded within the year preceeding surgery. OUTCOME MEASURES: Our primary outcome was major blood loss, defined as >2L of estimated blood loss, using the upper 90th percentile of our study population. METHODS: The lowest preoperative T-score was recorded. Patients were excluded who had liver/kidney disease or were on prescription anticoagulant medication. Binomial regression was performed controlling for age, number of vertebra fused, 3-column osteotomy, primary vs. revision surgery, preoperative platelet count, and if the patient was taking medication for osteoporosis. Significance was set at p=0.05. RESULTS: Mean age of patients was 63 § 11.6 years, 81% female. 56 (62%) of cases included revision of previous instrumentation. Patients had a mean SVA of 9.6 § 8.6cm and median of 9 vertebra fused (range 5-22). The average T-score was -1.2 § 1.0. Each point lower T-score was associated with significantly higher odds of major blood loss (OR 2.5, 95% CI 1.0 − 5.9) when controlling for age, number of vertebra fused, 3-column osteotomy, preoperative platelet count and primary vs. revision surgery. CONCLUSIONS: Lower preoperative T-score is independently associated with increased odds of significant blood loss in ASD surgery. Surgeons should anticipate increased blood loss in ASD patients with lower bone mineral density. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.452
P29. Caudally directed upper-instrumented vertebra pedicle screws minimize the risk of proximal junctional failure in patients with long posterior spinal fusion for adult spinal deformity Andrew B. Harris, BS1, Floreana K. Naef, MD2, Varun Puvanesarajah, MD3, Micheal Raad, MD4, Matthew W. Wilkening, MD5, David B. Cohen, MD, MPH2, Brian J. Neuman, MD4, Khaled M. Kebaish, MD2; 1 Johns Hopkins Hospital, Baltimore, MD, US; 2 Johns Hopkins University, Baltimore, MD, US; 3 Johns Hopkins Medicine, Baltimore, MD, US; 4 Baltimore, MD, US; 5 Belmont, MI, US BACKGROUND CONTEXT: Proximal junctional kyphosis (PJK) and Proximal Junctional Failure (PJF) are significant complications following Adult Spinal Deformity (ASD) surgery. Orientation of the Upper Instrumented Vertebra (UIV) pedicle screw has not been studied as a potential risk factor for PJK/PJF. PURPOSE: To demonstrate the association between UIV pedicle screw cranial-caudal trajectory and the development of both PJK and PJF in ASD patients with thoracolumbar fusion to the pelvis. STUDY DESIGN/SETTING: Retrospective case series. PATIENT SAMPLE: A total of 96 ASD patients (>5 levels fused) were identified from a multiprovider academic institution with fusion from T8T12 to pelvis and 2-year follow-up. OUTCOME MEASURES: Our primary outcomes were the development of PJK, defined as a proximal junction sagittal Cobb angle ≥10˚ and proximal junction sagittal Cobb angle ≥10˚ higher than preoperative measurement; and PJF, defined as revision surgery for PJK. METHODS: We defined a novel measurement of the UIV Screw Angle (UIVSA) as the mean of the angles between the UIV superior endplate and each UIV pedicle screw using intraoperative sagittal radiographs. A screw pointed cranially was measured as (+) UIVSA and a screw pointed caudally was measured as (-)UIVSA. A threshold UIVSA of +3˚ was determined by the maximum likelihood of PJK using the area under a Receiver Operating Curve. Using binary logistic regression, we examined the development of PJK and PJF in patients with UIVSA above and below +3˚, while controlling for preoperative TK, osteoporosis and age.
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.