Puvanesarajah Varun, Shen Francis H, Cancienne Jourdan M, Novicoff Wendy M, Jain Amit, Shimer Adam L, Hassanzadeh Hamid
Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia; and.
J Neurosurg Spine. 2016 Oct;25(4):486-493. doi: 10.3171/2016.2.SPINE151345. Epub 2016 May 6.
OBJECTIVE Surgical correction of adult spinal deformity (ASD) is a complex undertaking with high revision rates. The elderly population is poorly studied with regard to revision surgery, yet senior citizens constitute a rapidly expanding surgical demographic. Previous studies aimed at elucidating appropriate risk factors for revision surgery have been limited by small cohort sizes. The purpose of this study was to assess factors that modify the risk of revision surgery in elderly patients with ASD. METHODS The PearlDiver database (2005-2012) was used to determine revision rates in elderly ASD patients treated with a primary thoracolumbar posterolateral fusion of 8 or more levels. Analyzed risk factors included demographics, comorbid conditions, and surgical factors. Significant univariate predictors were further analyzed with multivariate analysis. The causes of revision at each year of follow-up were determined. RESULTS A total of 2293 patients who had been treated with posterolateral fusion of 8 or more levels were identified. At the 1-year follow-up, 241 (10.5%) patients had been treated with revision surgery, while 424 (18.5%) had revision surgery within 5 years. On univariate analysis, obesity was found to be a significant predictor of revision surgery at 1 year, while bone morphogenetic protein (BMP) use was found to significantly decrease revision surgery at 4 and 5 years of followup. Diabetes mellitus, osteoporosis, and smoking history were all significant univariate predictors of increased revision risk at multiple years of follow-up. Multivariate analysis at 5 years of follow-up revealed that osteoporosis (OR 1.98, 95% CI 1.60-2.46, p < 0.0001) and BMP use (OR 0.70, 95% CI 0.56-0.88, p = 0.002) were significantly associated with an increased and decreased revision risk, respectively. Smoking history trended toward significance (OR 1.37, 95% CI 1.10-1.70, p = 0.005). Instrument failure was consistently the most commonly cited reason for revision. Five years following surgery, it was estimated that the cohort had 68.8% survivorship. CONCLUSIONS For elderly patients with ASD, osteoporosis increases the risk of revision surgery, while BMP use decreases the risk. Other comorbidities were not found to be significant predictors of long-term revision rates. It is expected that within 5 years following the index procedure, over 30% of patients will require revision surgery.
目的 成人脊柱畸形（ASD）的手术矫正操作复杂，翻修率高。针对翻修手术对老年人群的研究较少，然而老年患者在接受手术治疗的人群中所占比例正在迅速扩大。以往旨在阐明翻修手术合适风险因素的研究因队列规模小而受到限制。本研究的目的是评估影响老年ASD患者翻修手术风险的因素。方法 使用PearlDiver数据库（2005 - 2012年）确定接受初次胸腰段后路融合术且融合节段达8个或更多节段的老年ASD患者的翻修率。分析的风险因素包括人口统计学特征、合并症和手术因素。对单因素分析中有显著意义的预测因素进一步进行多因素分析。确定随访各年的翻修原因。结果 共识别出2293例接受了8个或更多节段后路融合术的患者。在1年随访时，241例（10.5%）患者接受了翻修手术，而424例（18.5%）患者在5年内接受了翻修手术。单因素分析发现，肥胖是1年时翻修手术的显著预测因素，而使用骨形态发生蛋白（BMP）在随访4年和5年时显著降低了翻修手术的发生率。糖尿病、骨质疏松症和吸烟史在多年随访中均是翻修风险增加的显著单因素预测因素。随访5年时的多因素分析显示，骨质疏松症（比值比[OR] 1.98，95%置信区间[CI] 1.60 - 2.46，p < 0.0001）和使用BMP（OR 0.70，9% CI 0.56 - 0.88，p = 0.002）分别与翻修风险增加和降低显著相关。吸烟史有显著趋势（OR 1.37，95% CI 1.10 - 1.70，p = 0.005）。内固定失败一直是最常被提及的翻修原因。手术后5年，估计该队列的生存率为68.8%。结论 对于老年ASD患者，骨质疏松症增加了翻修手术的风险，而使用BMP降低了风险。未发现其他合并症是长期翻修率的显著预测因素。预计在初次手术后5年内，超过30%的患者将需要翻修手术。
