Surgery Shows Measurable Benefits for Patients with Adult Spinal Deformity

Study earns one of the Congress of Neurological Surgeons' 2017 Paper of the Year awards.

Research from the International Spine Study Group (ISSG) found that surgery for adult spinal deformity (ASD) can provide significant improvement of pain, disability, and general health-related quality of life (HRQOL) at a minimum of 2-year follow-up compared to nonoperative treatments. The study, which was originally published in the June 2016 issue of Neurosurgery, earned runner-up in the Top Paper of the Year category in the first-ever Congress of Neurological Surgeons 2017 Paper of the Year awards.
Illustration of the vertebral columnResearch found that surgery for adult spinal deformity can provide significant improvement of pain, disability, and general health-related quality of life.Surgery for ASD: High Risk, High Reward
The study, which was an extensive prospective multicenter collaborative effort conducted through the ISSG, compared surgical and nonsurgical outcomes in patients with ASD—a condition that can have a major impact on HRQOL.

ASD treatment options span a wide spectrum, says lead author Justin S. Smith, MD, PhD. On the nonoperative side, physical therapy, steroid injections, opioid and nonopioid medications, and alternative treatments (eg, acupuncture, yoga) may be used. Surgery may also be an option for some patients with significant symptoms, he says, but ASD surgery is often substantial, bears complication risks, and comes with a long road to recovery.

Studies showing whether the benefits of ASD surgery are worth the risk is largely uncharted territory, Dr. Smith says.

“There are very few studies in the literature that provide high-quality data on expected outcomes of operative treatment for ASD and even fewer that compare the benefits of surgery with those of nonoperative treatment approaches,” Dr. Smith says. “This information would be of great value to patients, surgeons, and payers.”

A Look at the Study—Including 2 Surprising Findings
The research team assessed outcomes of 286 surgical patients with ASD and 403 nonoperative patients (86% and 55% 2-year follow-up rates, respectively). At baseline, patients undergoing surgery had worse HRQOL and worse spinal deformity based on pelvic tilt, pelvic incidence-to-lumbar lordosis mismatch, and sagittal vertical axis.

At the minimum 2-year follow up, the researchers found patients who had surgery for ASD showed meaningful improvement of pain, disability, and general HRQOL (P < .001). Also at the 2-year follow-up, 71.5% of patients who had surgery had ≥1 complications. On the other hand, patients who underwent nonoperative treatments, on average, only maintained the presenting levels of pain and disability.

Dr. Smith said two findings from the study surprised him.
First, he notes the complication rate associated with ASD surgical procedures is high. Dr. Smith says ISSG meticulously and prospectively collects complications using standardized data sheets, and each site that contributes patients has at least one on-site study coordinator who actively collects complications.

“Fortunately, many, if not most, of these complications likely have little or no impact on the ultimate clinical outcome for the patient, but they may impact the length of hospital stay, need for further invasive procedures (including reoperation), can negatively impact the patient recovery, and may significantly increase the cost of care,” he says.

Age plays a big factor in complication rate, Dr. Smith says, but older patients also see the greatest benefit from surgery.

“Although the older patients had, by far, the highest risks of complications, these were the patients who started out with the greatest disability and pain, and ultimately were the ones who improved the most with surgery,” he says. “So, despite facing the greatest risk of complications, it was the elderly that still stood to gain the most from surgical treatment.”

A second surprising finding was that there was a subset of patients treated nonoperatively that appeared to achieve a satisfactory improvement of pain and disability over the minimum 2-year follow-up.

“Notably, this was a small subset—and there were others who worsened, such that the average was essentially no change over the 2 years in this group of patients,” Dr. Smith says.

Further study is needed to identify the subset of patients most likely to benefit from nonoperative treatment and assess the long-term durability of such treatment.

Looking to the Future of ASD Treatment
When asked what future studies on ASD treatment are needed, Dr. Smith says that it’s important to continue developing approaches and techniques to improve the safety of surgical treatment for ASD.

“ISSG and others have made great progress in reducing many of the major complications (eg, reduction of rod fractures using different rod configurations, reduction of infection rates using vancomycin powder in the wound, reduction of excessive blood loss with intraoperative tranexamic acid),” Dr. Smith says. “However, there is still much progress to be made.”

Dr. Smith also says the ISSG is actively leveraging its large database of ASD patients, along with advanced predictive analytics tools, to develop predictive models that will enhance patient counseling, treatment planning, and the overall safety and cost-effectiveness of patient care.

More About the CNS Paper of the Year Awards
This study is among the 10 winners of CNS’ inaugural Paper of the Year awards, which honor the best-in-class papers published in the organization’s journal, Neurosurgery.

Papers published in Neurosurgery between June 2016 and June 2017 were eligible to earn this year’s award. The winning papers “challenged dogma, created a paradigm shift, and inspired neurosurgeons to rethink their approaches to patient care, big data, and trial results,” according to a CNS news release.

The winning papers, which all underwent a scrupulous review process, will be recognized at the 2017 CNS Annual Meeting in Boston on October 7-11.

Updated on: 02/08/18
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