The impact of postoperative neurologic complications on recovery kinetics in cervical deformity surgery
Peter Gust Passias1, Avery E Brown1, Haddy Alas1, Katherine E Pierce1, Cole A Bortz1, Bassel Diebo2, Renaud Lafage3, Virginie Lafage4, Douglas C Burton5, Robert Hart6, Han Jo Kim3, Shay Bess7, Kevin Moattari1, Rachel Joujon-Roche1, Oscar Krol1, Tyler Williamson1, Peter Tretiakov1, Bailey Imbo1, Themistocles S Protopsaltis1, Christopher Shaffrey8, Frank Schwab3, Robert Eastlack9, Breton Line7, Eric Klineberg10, Justin Smith11, Christopher Ames12, On behalf of the International Spine Study Group13
1 Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
2 Deparment of Orthopaedic Surgery, SUNY Downstate, New York, NY, USA
3 Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
4 Lenox Hill Hospital, Northwell Health, Department of Orthopaedics, New York, NY, USA
5 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
6 Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
7 Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
8 Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
9 Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
10 Department of Orthopaedic Surgery, University of California, Davis, CA, USA
11 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
12 Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
Peter Gust Passias
Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, 301 East 17th St., New York, NY 10003
Source of Support: None, Conflict of Interest: None
Objective: The objective of the study is to investigate which neurologic complications affect clinical outcomes the most following cervical deformity (CD) surgery.
Methods: CD patients (C2-C7 Cobb >10°, CL >10°, cSVA >4 cm or chin-brow vertical angle >25°) >18 years with follow-up surgical and health-related quality of life (HRQL) data were included. Descriptive analyses assessed demographics. Neurologic complications assessed were C5 motor deficit, central neurodeficit, nerve root motor deficits, nerve sensory deficits, radiculopathy, and spinal cord deficits. Neurologic complications were classified as major or minor, then: intraoperative, before discharge, before 30 days, before 90 days, and after 90 days. HRQL outcomes were assessed at 3 months, 6 months, and 1 year. Integrated health state (IHS) for the neck disability index (NDI), EQ5D, and modified Japanese Orthopaedic Association (mJOA) were assessed using all follow-up time points. A subanalysis assessed IHS outcomes for patients with 2Y follow-up.
Results: 153 operative CD patients were included. Baseline characteristics: 61 years old, 63% female, body mass index 29.7, operative time 531.6 ± 275.5, estimated blood loss 924.2 ± 729.5, 49% posterior approach, 18% anterior approach, 33% combined. 18% of patients experienced a total of 28 neurologic complications in the postoperative period (15 major). There were 7 radiculopathy, 6 motor deficits, 6 sensory deficits, 5 C5 motor deficits, 2 central neurodeficits, and 2 spinal cord deficits. 11.2% of patients experienced neurologic complications before 30 days (7 major) and 15% before 90 days (12 major). 12% of neurocomplication patients went on to have revision surgery within 6 months and 18% within 2 years. Neurologic complication patients had worse mJOA IHS scores at 1Y but no significant differences between NDI and EQ5D (0.003 vs. 0.873, 0.458). When assessing individual complications, central neurologic deficits and spinal cord deficit patients had the worst outcomes at 1Y (2.6 and 1.8 times worse NDI scores, P = 0.04, no improvement in EQ5D, 8% decrease in EQ5D). Patients with sensory deficits had the best NDI and EQ5D outcomes at 1Y (31% decrease in NDI, 8% increase in EQ5D). In a subanalysis, neurologic patients trended toward worse NDI and mJOA IHS outcomes (P = 0.263, 0.163).
Conclusions: 18% of patients undergoing CD surgery experienced a neurologic complication, with 15% within 3 months. Patients who experienced any neurologic complication had worse mJOA recovery kinetics by 1 year and trended toward worse recovery at 2 years. Of the neurologic complications, central neurologic deficits and spinal cord deficits were the most detrimental.