Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery

Authors

Peter G Passias
Tyler K Williamson
Jamshaid M Mir
Justin S Smith
Virginie Lafage
Renaud Lafage
Breton Line
Alan H Daniels
Jeffrey L Gum
Andrew J Schoenfeld
David Kojo Hamilton
Alex Soroceanu
Justin K Scheer
Robert Eastlack
Gregory M Mundis
Bassel Diebo
Khaled M Kebaish
Richard A Hostin
Munish C Gupta
Han Jo Kim
Eric O Klineberg
Christopher P Ames
Robert A Hart
Douglas C Burton
Frank J Schwab
Christopher I Shaffrey
Shay Bess
International Spine Study Group

Publication Date

8-26-2023

Journal

International of Clinical Medicine

Abstract

BACKGROUND: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.

OBJECTIVE: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers.

STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected multicenter database.

METHODS: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility.

RESULTS: A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%,

CONCLUSIONS: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.

Keywords

adult spinal deformity, cost-utility, complications, complex realignment, Medicare, clinical improvement

Comments

PMID: 37685633