Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management

Peter G. Passias; Waleed Ahmad; Peter Tretiakov; Oscar Krol; Frank Segreto; Renaud Lafage; Virginie Lafage; Alex Soroceanu; Alan Daniels; Jeffrey Gum; Breton Line; Andrew J. Schoenfeld; Shaleen Vira; Robert Hart; Douglas Burton; Justin S. Smith; Christopher P. Ames; Christopher Shaffrey; Frank Schwab; Shay Bess

doi:10.1227/neu.0000000000002447

Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management

Peter G. Passias, Waleed Ahmad, Peter Tretiakov, Oscar Krol, Frank Segreto, Renaud Lafage, Virginie Lafage, Alex Soroceanu, Alan Daniels, Jeffrey Gum, Breton Line, Andrew J. Schoenfeld, Shaleen Vira, Robert Hart, Douglas Burton, Justin S. Smith, Christopher P. Ames, Christopher Shaffrey, Frank Schwab, Shay Bess

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND: Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms. OBJECTIVE: To examine the factors associated with successful nonoperative management in patients with ASD. METHODS: We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis. RESULTS: In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P <.05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P <.05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P <.001) were significantly more likely to achieve nonoperative success. CONCLUSION: Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.

Original language	English (US)
Pages (from-to)	480-488
Number of pages	9
Journal	Neurosurgery
Volume	93
Issue number	2
DOIs	https://doi.org/10.1227/neu.0000000000002447
State	Published - Aug 1 2023

Keywords

Adult spinal deformity
Nonoperative
Nonoperative management
Spine
Spine surgery
Thoracolumbar spine

ASJC Scopus subject areas

Surgery
Clinical Neurology

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10.1227/neu.0000000000002447

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Passias, P. G., Ahmad, W., Tretiakov, P., Krol, O., Segreto, F., Lafage, R., Lafage, V., Soroceanu, A., Daniels, A., Gum, J., Line, B., Schoenfeld, A. J., Vira, S., Hart, R., Burton, D., Smith, J. S., Ames, C. P., Shaffrey, C., Schwab, F., & Bess, S. (2023). Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management. Neurosurgery, 93(2), 480-488. https://doi.org/10.1227/neu.0000000000002447

Passias, PG, Ahmad, W, Tretiakov, P, Krol, O, Segreto, F, Lafage, R, Lafage, V, Soroceanu, A, Daniels, A, Gum, J, Line, B, Schoenfeld, AJ, Vira, S, Hart, R, Burton, D, Smith, JS, Ames, CP, Shaffrey, C, Schwab, F & Bess, S 2023, 'Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management', Neurosurgery, vol. 93, no. 2, pp. 480-488. https://doi.org/10.1227/neu.0000000000002447

@article{b209912765e54d6b9b9d1024ceed9c4c,

title = "Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management",

abstract = "BACKGROUND: Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms. OBJECTIVE: To examine the factors associated with successful nonoperative management in patients with ASD. METHODS: We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis. RESULTS: In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P <.05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P <.05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P <.001) were significantly more likely to achieve nonoperative success. CONCLUSION: Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.",

keywords = "Adult spinal deformity, Nonoperative, Nonoperative management, Spine, Spine surgery, Thoracolumbar spine",

author = "Passias, {Peter G.} and Waleed Ahmad and Peter Tretiakov and Oscar Krol and Frank Segreto and Renaud Lafage and Virginie Lafage and Alex Soroceanu and Alan Daniels and Jeffrey Gum and Breton Line and Schoenfeld, {Andrew J.} and Shaleen Vira and Robert Hart and Douglas Burton and Smith, {Justin S.} and Ames, {Christopher P.} and Christopher Shaffrey and Frank Schwab and Shay Bess",

note = "Funding Information: Robert Hart: ISSG: Board; DePuy: Consulting, speaker, royalties, research support; Globus Medical: IP royalties; Paid consultant; Paid presenter or speaker; International Spine Study Group: Board or committee member; ISSLS Textbook of the Lumbar Spine: Editorial or governing board; Medtronic: Paid consultant; Paid presenter or speaker; SeaSpine: IP royalties; Paid Consultant; Spine Connect: Stock or stock Options; Advisory Board Member; MiRus: Paid Consultant. Douglas Burton: Globus and Blue Ocean Spine: financial relationships; Bioventus: Research support; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Pfizer: Research support; Progenerative Medical: Stock or stock Options; Scoliosis Research Society: Board or committee member; Spine Deformity: Editorial or governing board. Justin S. Smith: Alphatec Spine: Stock or stock Options; Carlsmed: Paid consultant; Cerapedics: Paid consultant; DePuy: Research support; DePuy, A Johnson & Johnson Company: Paid consultant; ISSG: Executive committee; Journal of Neurosurgery Spine: Editorial or governing board; Neurospine: Editorial or governing board; Neurosurgery: Editorial or governing board; Nuvasive: IP royalties; Paid consultant; Research support; Operative Neurosurgery: Editorial or governing board; Scoliosis Research Society: Board or committee member; SeaSpine: financial relationships; Spine Deformity: Editorial or governing board; Stryker: Paid consultant; Thieme: Publishing royalties, financial or material support; Zimmer: IP royalties; Paid consultant. Christopher P. Ames: Biomet Spine: IP royalties; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Global Spine Analytics—Director: Other financial or material support; International Spine Study Group (ISSG): Research support; International Spine Study Group (ISSG)—Executive Committee: Other financial or material support; K2M: IP royalties; Paid consultant; Medicrea: IP royalties; Paid consultant; Medtronic: Paid consultant; Next Orthosurgical: IP royalties; Nuvasive: IP royalties; Operative Neurosurgery—Editorial Board: Other financial or material support; Scoliosis Research Society (SRS)—Grant Funding: Other financial or material support; Stryker: IP royalties; Titan Spine: Research support. Christopher Shaffrey: AANS: Board or committee member; Cervical Spine Research Society: Board or committee member; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Research support; Globus Medical: Research support; Medtronic: Other financial or material support; Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Research support; Neurosurgery RRC: Board or committee member; Nuvasive: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Stock or stock Options; Proprio, SI Bone: IP royalties; Spinal Deformity: Editorial or governing board; Spine: Editorial or governing board; Zimmer Biomet: financial relationship. Frank Schwab: DePuy, A Johnson & Johnson Company: Research support; Globus Medical: Paid consultant; Paid presenter or speaker; K2M: IP royalties; Paid consultant; Paid presenter or speaker; Medicrea: Royalties; Medtronic: Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Nuvasive: Research support; Scoliosis Research Society: Board or committee member; Spine Deformity: Editorial or governing board; See Spine: Shareholder/non-compensated; Stryker: Research support; VFT Solutions: Shareholder/non-compensated; VP of International Spine Society Group (ISSG): Board or committee member; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker. Shay Bess: DePuy, A Johnson & Johnson Company: Research support; Alphatec/EOS; Paid consultant; Carlsmed: research support; Globus Medical: Research support; k2 medical: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Medtronic Sofamor Danek: Research support; North American Spine Society: Board or committee member; Nuvasive: IP royalties; Research support; Orthofix, Inc.: Research support; Scoliosis Research Society: Board or committee member; Sea Spine: Research support; Stryker: IP royalties; Paid presenter or speaker. The International Spine Study Group (ISSG) is funded through research grants from DePuy Synthes and individual donations. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Funding Information: The ISSG supported this study. Andrew J. Shoenfeld has funding from NIH-NIAMS, US Department of Defense, and OREF. Justin S. Smith has funding from NREF and AOSpine. Publisher Copyright: {\textcopyright} 2023 Congress of Neurological Surgeons. All rights reserved.",

year = "2023",

month = aug,

day = "1",

doi = "10.1227/neu.0000000000002447",

language = "English (US)",

volume = "93",

pages = "480--488",

journal = "Neurosurgery",

issn = "0148-396X",

publisher = "Lippincott Williams and Wilkins Ltd.",

number = "2",

}

TY - JOUR

T1 - Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management

AU - Passias, Peter G.

AU - Ahmad, Waleed

AU - Tretiakov, Peter

AU - Krol, Oscar

AU - Segreto, Frank

AU - Lafage, Renaud

AU - Lafage, Virginie

AU - Soroceanu, Alex

AU - Daniels, Alan

AU - Gum, Jeffrey

AU - Line, Breton

AU - Schoenfeld, Andrew J.

AU - Vira, Shaleen

AU - Hart, Robert

AU - Burton, Douglas

AU - Smith, Justin S.

AU - Ames, Christopher P.

AU - Shaffrey, Christopher

AU - Schwab, Frank

AU - Bess, Shay

N1 - Funding Information: Robert Hart: ISSG: Board; DePuy: Consulting, speaker, royalties, research support; Globus Medical: IP royalties; Paid consultant; Paid presenter or speaker; International Spine Study Group: Board or committee member; ISSLS Textbook of the Lumbar Spine: Editorial or governing board; Medtronic: Paid consultant; Paid presenter or speaker; SeaSpine: IP royalties; Paid Consultant; Spine Connect: Stock or stock Options; Advisory Board Member; MiRus: Paid Consultant. Douglas Burton: Globus and Blue Ocean Spine: financial relationships; Bioventus: Research support; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Pfizer: Research support; Progenerative Medical: Stock or stock Options; Scoliosis Research Society: Board or committee member; Spine Deformity: Editorial or governing board. Justin S. Smith: Alphatec Spine: Stock or stock Options; Carlsmed: Paid consultant; Cerapedics: Paid consultant; DePuy: Research support; DePuy, A Johnson & Johnson Company: Paid consultant; ISSG: Executive committee; Journal of Neurosurgery Spine: Editorial or governing board; Neurospine: Editorial or governing board; Neurosurgery: Editorial or governing board; Nuvasive: IP royalties; Paid consultant; Research support; Operative Neurosurgery: Editorial or governing board; Scoliosis Research Society: Board or committee member; SeaSpine: financial relationships; Spine Deformity: Editorial or governing board; Stryker: Paid consultant; Thieme: Publishing royalties, financial or material support; Zimmer: IP royalties; Paid consultant. Christopher P. Ames: Biomet Spine: IP royalties; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Global Spine Analytics—Director: Other financial or material support; International Spine Study Group (ISSG): Research support; International Spine Study Group (ISSG)—Executive Committee: Other financial or material support; K2M: IP royalties; Paid consultant; Medicrea: IP royalties; Paid consultant; Medtronic: Paid consultant; Next Orthosurgical: IP royalties; Nuvasive: IP royalties; Operative Neurosurgery—Editorial Board: Other financial or material support; Scoliosis Research Society (SRS)—Grant Funding: Other financial or material support; Stryker: IP royalties; Titan Spine: Research support. Christopher Shaffrey: AANS: Board or committee member; Cervical Spine Research Society: Board or committee member; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Research support; Globus Medical: Research support; Medtronic: Other financial or material support; Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Research support; Neurosurgery RRC: Board or committee member; Nuvasive: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Stock or stock Options; Proprio, SI Bone: IP royalties; Spinal Deformity: Editorial or governing board; Spine: Editorial or governing board; Zimmer Biomet: financial relationship. Frank Schwab: DePuy, A Johnson & Johnson Company: Research support; Globus Medical: Paid consultant; Paid presenter or speaker; K2M: IP royalties; Paid consultant; Paid presenter or speaker; Medicrea: Royalties; Medtronic: Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Nuvasive: Research support; Scoliosis Research Society: Board or committee member; Spine Deformity: Editorial or governing board; See Spine: Shareholder/non-compensated; Stryker: Research support; VFT Solutions: Shareholder/non-compensated; VP of International Spine Society Group (ISSG): Board or committee member; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker. Shay Bess: DePuy, A Johnson & Johnson Company: Research support; Alphatec/EOS; Paid consultant; Carlsmed: research support; Globus Medical: Research support; k2 medical: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Medtronic Sofamor Danek: Research support; North American Spine Society: Board or committee member; Nuvasive: IP royalties; Research support; Orthofix, Inc.: Research support; Scoliosis Research Society: Board or committee member; Sea Spine: Research support; Stryker: IP royalties; Paid presenter or speaker. The International Spine Study Group (ISSG) is funded through research grants from DePuy Synthes and individual donations. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Funding Information: The ISSG supported this study. Andrew J. Shoenfeld has funding from NIH-NIAMS, US Department of Defense, and OREF. Justin S. Smith has funding from NREF and AOSpine. Publisher Copyright: © 2023 Congress of Neurological Surgeons. All rights reserved.

PY - 2023/8/1

Y1 - 2023/8/1

N2 - BACKGROUND: Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms. OBJECTIVE: To examine the factors associated with successful nonoperative management in patients with ASD. METHODS: We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis. RESULTS: In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P <.05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P <.05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P <.001) were significantly more likely to achieve nonoperative success. CONCLUSION: Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.

AB - BACKGROUND: Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms. OBJECTIVE: To examine the factors associated with successful nonoperative management in patients with ASD. METHODS: We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis. RESULTS: In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P <.05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P <.05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P <.001) were significantly more likely to achieve nonoperative success. CONCLUSION: Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.

KW - Adult spinal deformity

KW - Nonoperative

KW - Nonoperative management

KW - Spine

KW - Spine surgery

KW - Thoracolumbar spine

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U2 - 10.1227/neu.0000000000002447

DO - 10.1227/neu.0000000000002447

M3 - Article

C2 - 36942962

AN - SCOPUS:85165220221

SN - 0148-396X

VL - 93

SP - 480

EP - 488

JO - Neurosurgery

JF - Neurosurgery

IS - 2

ER -

Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management

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