Passias Peter G, Tretiakov Peter, Onafowokan Oluwatobi O, Das Ankita, Lafage Renaud, Smith Justin S, Line Breton G, Nayak Pratibha, Diebo Bassel, Daniels Alan H, Gum Jeffrey L, Hamilton D Kojo, Buell Thomas J, Soroceanu Alex, Scheer Justin K, Eastlack Robert K, Mullin Jeffrey P, Schoenfeld Andrew J, Mundis Gregory M, Hosogane Naobumi, Yagi Mitsuru, Mummaneni Praveen V, Chou Dean, Fu Kai-Ming, Than Khoi D, Anand Neel, Okonkwo David O, Wang Michael Y, Klineberg Eric, Kebaish Khaled M, Lewis Stephen, Hostin Richard, Gupta Munish, Lenke Lawrence, Kim Han Jo, Ames Christopher P, Shaffrey Christopher I, Bess Shay, Schwab Frank, Lafage Virginie, Burton Douglas
1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, Duke University Medical Center, Durham, North Carolina.
2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York.
J Neurosurg Spine. 2024 Nov 22;42(2):185-192. doi: 10.3171/2024.8.SPINE24365. Print 2025 Feb 1.
The objective of this study was to identify baseline patient and surgical factors predictive of optimal outcomes in staged versus same-day combined-approach surgery.
Adult spinal deformity (ASD) patients with baseline and perioperative (by 6 weeks) data were stratified based on single-stage (same-day) or multistage (staged) surgery, excluding planned multiple hospitalizations. Means comparison analyses were used to assess baseline demographic, radiographic, and surgical differences between cohorts. Backstep logistic regression and conditional inference tree analysis were used to identify variable thresholds associated with study-specific definitions of an optimal outcome in each cohort, defined as no intraoperative or surgery-related in-hospital adverse event.
There were 439 patients with complex ASD in the dataset (mean age 64.0 ± 9.3 years, 68% female, mean BMI 28.7 ± 5.5 kg/m2). Overall, 58.8% of patients were in the same-day group, while 41.2% were in the staged group. Demographically, cohorts were not significantly different (p > 0.05), but staged patients were more frail per total Edmonton Frail Scale score (p = 0.043). Staged patients also reported greater numeric rating scale scores for back pain than same-day patients (p = 0.002). Cohorts were comparable in magnitude of planned correction of C7-S1 sagittal vertical axis, pelvic incidence-lumbar lordosis (PI-LL) mismatch, and T4-12 kyphosis (all p > 0.05). Controlling for baseline age, frailty, and number of levels fused, staged patients reported significantly higher PROMIS Discretionary Social Activities scores by 6 weeks (p = 0.029). Radiographic outcomes by 6 weeks were comparable between cohorts, in terms of both magnitude of change from baseline and overall result (all p > 0.05). Same-day patients were significantly more likely to experience in-hospital complications (p = 0.013). When considering frailty thresholds for staging, only a Charlson Comorbidity Index ≤ 1.0 was associated with optimal outcome in same-day patients, while Edmonton Frail Scale score ≥ 7 (p = 0.036), ≥ 9 levels fused (p = 0.016), and baseline PI-LL mismatch ≥ 15.3° (p = 0.028) were associated with optimal outcome for staged patients. Yet, staging alone was not significantly associated with an optimal outcome perioperatively (p = 0.056).
While staged and same-day combined-approach surgeries yield comparable radiographic and patient-reported outcomes, certain subsets of complex ASD patients may benefit from staged surgery despite the invariably increased hospital length of stay. Individuals with increased frailty, moderate to severe PI-LL mismatch, and increased anticipated number of levels fused may experience a lower risk of perioperative adverse events if they undergo a staged procedure. Clinical trial registration no.: NCT04194138 (ClinicalTrials.gov).
本研究的目的是确定在分期手术与同日联合入路手术中预测最佳预后的基线患者因素和手术因素。
收集具有基线和围手术期（至6周）数据的成人脊柱畸形（ASD）患者，根据单阶段（同日）或多阶段（分期）手术进行分层，排除计划中的多次住院情况。采用均值比较分析来评估队列之间的基线人口统计学、影像学和手术差异。使用向后逐步逻辑回归和条件推断树分析来确定与每个队列中最佳预后的特定研究定义相关的变量阈值，最佳预后定义为无术中或与手术相关的院内不良事件。
数据集中有439例复杂ASD患者（平均年龄64.0±9.3岁，68%为女性，平均BMI 28.7±5.5kg/m²）。总体而言，58.8%的患者在同日组，而41.2%在分期组。在人口统计学方面，队列之间无显著差异（p>0.05），但根据埃德蒙顿衰弱量表总分，分期患者更虚弱（p = 0.043）。分期患者报告的背痛数字评分量表得分也高于同日患者（p = 0.002）。队列在C7-S1矢状垂直轴、骨盆入射角-腰椎前凸（PI-LL）不匹配和T4-12后凸畸形的计划矫正幅度方面具有可比性（均p>0.05）。在控制基线年龄、虚弱程度和融合节段数量后，分期患者在6周时报告的PROMIS自主社交活动得分显著更高（p = 0.029）。在6周时的影像学结果方面，队列之间在与基线的变化幅度和总体结果方面均具有可比性（均p>0.05）。同日患者发生院内并发症的可能性显著更高（p = 0.013）。在考虑分期的虚弱阈值时，仅查尔森合并症指数≤1.0与同日患者的最佳预后相关，而埃德蒙顿衰弱量表得分≥7（p = 0.036）、融合节段≥9个（p = 0.016）以及基线PI-LL不匹配≥15.3°（p = 0.028）与分期患者的最佳预后相关。然而，单独的分期在围手术期与最佳预后无显著相关性（p = 0.056）。
虽然分期和同日联合入路手术产生了可比的影像学和患者报告结果，但某些复杂ASD患者亚组可能从分期手术中获益，尽管住院时间必然增加。虚弱程度增加、中度至重度PI-LL不匹配以及预期融合节段数量增加的个体如果接受分期手术，可能经历较低的围手术期不良事件风险。临床试验注册号：NCT04194138（ClinicalTrials.gov）。
