1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital, New York, New York.
2New York Spine Institute, New York, New York.
J Neurosurg Spine. 2023 Jul 28;39(5):628-635. doi: 10.3171/2023.5.SPINE23457. Print 2023 Nov 1.
The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized.
Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications.
Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048).
Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.
本研究旨在探讨高危患者的手术是否随着时间的推移而得到优化，以及是否可以最大限度地减少不良预后。
本研究纳入了 2013 年至 2018 年期间接受颈椎畸形（CD）手术且年龄≥18 岁、基线和 2 年数据均完整的患者。根据手术年份将患者分为两组：2013 年至 2015 年期间手术的患者为早期组，2016 年至 2018 年期间手术的患者为近期组。高危患者至少符合以下 2 项标准：1）基线 C2-7 Cobb 角>15°，T1 斜率与颈椎前凸的差值≥35°，C2-7 矢状垂直轴>4cm，或颏眉垂直角>25°；2）年龄≥70 岁；3）严重基线虚弱（Miller 指数）；4）Charlson 合并症指数（CCI）高于平均值 1 个标准差；5）采用三柱截骨术治疗；6）融合>10 个节段或老年患者>7 个节段。采用均值比较分析评估两组间的差异。逐步多元线性回归描述了手术年份增加与并发症之间的关联。
82 例 CD 患者符合高危标准（平均年龄 62.11±10.87 岁，女性占 63.7%，平均 BMI 为 29.70±8.16kg/m2，平均 CCI 为 1.07±1.45）。高危患者的比例随时间增加而增加，早期组中有 41.8%的患者被归类为高危，而近期组中有 47.6%的患者为高危（p>0.05）。近期高危患者更可能为女性（p=0.008），BMI 更低（p=0.038），基线 CCI 更高（p=0.013）。手术方面，近期高危患者更可能接受低级别截骨术（p=0.003）。术后并发症方面，近期高危患者总体上发生任何术后不良事件的可能性较低（p=0.020），2 年后发生吞咽困难等并发症的可能性也较低（p=0.045）。回归分析显示，手术年份的增加与小并发症发生率的降低相关（p=0.030），2 年后远端交界性后凸的发生率也降低（p=0.048）。
随着时间的推移，高危 CD 患者的发病率和合并症发生率有所增加，但术后结局有所改善。这些发现表明，脊柱外科医生在高危患者的选择和减少潜在不良事件方面的能力随着时间的推移而得到了提高。
