Journal of Spinal Disorders and Techniques Publish Ahead of Print DOI:10.1097/BSD.0000000000000148
TITLE PAGE Title: Associations between Body Mass and Revision Surgical Outcomes in Adult Scoliosis. Authors: Lingjie Fu, MD, PhD1, Michael S. Chang, MD 2-4, Dennis G. Crandall, MD 2-4, Jan Revella, RN3 Authors affiliation: 1- Department of Orthopaedic Surgery, Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P. R. China. 2- Sonoran Spine Center, Phoenix, Arizona. 3- Sonoran Spine Research and Education Foundation, Phoenix, Arizona. 4- Banner Good Samaritan Orthopedic Surgery Residency Program, Phoenix, Arizona.
Conflicts of Interest L Fu – nothing to disclose M Chang – Globus – board membership, consultant, speakers bureau; Integra – consultant, speakers bureau; Medtronic – research support (past), speakers bureau; Medicrea – research support (unrelated); Synthes – speakers bureau; Stryker – speakers bureau D Crandall – Medtronic – consultant, research support (past), speakers bureau, royalties; CoAlign – consultant, stockholder; Ellipse – consultant, stockholder; Spinewave – consultant; Medicrea – research support (unrelated) J Revella – Employment Correspondence and reprints: Michael S. Chang 1432 S. Dobson, Suite 201 Mesa, Arizona 85202
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Abstract Study Design. Retrospective cohort study. Objective. To determine if an association exists between high body mass (BMI >25) and surgical outcomes in revision adult scoliosis patients. Summary of Background Data. Obesity is thought to be associated with increased surgical complications and inferior clinical outcomes in adults. There are no studies analyzing the effect of obesity on surgical outcomes in revision patients for adult scoliosis. Methods. Forty-five consecutive revision adult scoliosis patients (35 women and 10 men; mean age 62.7 ± 9.3) with a minimum follow-up of 2 years were included in this study. Patients were divided into 2 groups according to body mass index (BMI): overweight (BMI ≥ 25 kg/m2, n = 27) and non-overweight (< 25 kg/m2, n = 18). Radiographic measures, Oswestry disability index (ODI), Visual analog scale (VAS), as well as comorbidities and complications were reviewed and compared at pre-op and 2-year follow-up. Results. No significant differences in surgical methods, complication rates, or radiographic measures were found between the 2 groups except for the greater pre-op and final follow-up thoracic kyphosis in the overweight group (P < 0.05). A higher comorbidity rate of circulatory disorders (33.3% vs. 0%, P = 0.018) and diabetes (25.9% vs. 0%, P = 0.053) was observed in the overweight group, as well as a higher preoperative VAS score (7.1 ± 1.7 vs. 5.2 ± 2.9, P = 0.031). At 2-year follow-up, VAS and ODI improvements for both groups showed significant and similar improvement from preoperative (P < 0.01). Conclusion. Overweight revision adult scoliosis patients had higher thoracic kyphosis and more significant preoperative pain compared with normal-weight individuals. Overweight patients also had significantly higher rates of medical co-morbidities. However, BMI did not affect the functional outcome of surgical correction or perioperative complication rates. Overweight patients benefited from surgery just as much as non-overweight patients at 2-year follow-up.
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Key words: body mass index, obesity, adult scoliosis, revision surgery, surgical outcomes, complications.
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Excess body weight is a major public health concern. In 2008, an estimated 1.46 billion adults worldwide were found to be overweight; of these, 205 million men and 297 million women were obese.1 In the United States, the prevalence of obesity was 35.5% among adult men and 35.8% among adult women in 2009-2010.2 These proportions continue to rise. Several studies report that obesity has been associated with a variety of health problems.3-5 Obese adults have a greater risk of developing hypertension, diabetes mellitus, sleep apnea, cardiovascular disease, and osteoarthritis.3-5 For the spine, obesity has been correlated with an increased incidence of spinal degeneration, particularly in the lumbar region.6 Revision of adult spinal deformity continues to challenge both patients and surgeons.7-14 A recent study by Cho et al,15 who analyzed 126 adult scoliosis patients, reported that revision patients had a significantly higher overall complication rate compared with primary patients. Yet despite the risks of revision surgery, there is an increasing demand for operative intervention by the current aging population. Adult obesity has also been associated with an increased rate of postoperative complications and inferior surgical outcomes.16-17 A recent large cohort study found that obesity was associated with a higher degree of dissatisfaction and a lower functional outcome measured by the Oswestry Disability Index (ODI) and the EuroQol Group Index (EQ-5D) after surgery for lumbar spinal stenosis.18 Moreover, increased rates of comorbidities, wound-related complications, and longer operative times have been noted in obese patients undergoing lumbar spinal fusion.19 Chen et al20 found that overweight adult idiopathic scoliotic patients had similar postoperative complication rates compared with non-overweight patients. Another study by Hardesty et al21 found that obese patients are at higher risk for perioperative complications including increased operative time, increased blood loss, exacerbated third-spacing, and difficulty with administration of spinal anesthesia. However, the effect of body mass on surgical outcomes in adult scoliosis patients undergoing revision surgery has not been evaluated previously. The purpose of the current study is to perform a retrospective cohort analysis to
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determine if an association exists between BMI and radiographic parameters, Oswestry disability index (ODI), Visual analog scale (VAS), as well as comorbidities and complications in revision adult scoliosis patients. We hypothesized that patients with BMI greater than 25 have: ⑴ inferior coronal and sagittal deformity correction, ⑵ increased complication rates, and ⑶ inferior clinical outcomes; compared with patients with normal body mass (BMI 21 years old at the time of operation) at a single spine center undergoing revision surgery ≥ 4 levels for idiopathic or de novo scoliosis were prospectively enrolled in a surgical database. Clinical and radiographic data were collected on each patient at each office visit (1.5, 3, 6, 12 and 24 months post-op). Revision adult scoliosis patients were divided into 2 groups: overweight (BMI ≥ 25 kg/m2, n = 27) and non-overweight (< 25 kg/m2, n = 18), based on body mass index (BMI).22 The primary surgeries for these patients were all performed at our center and all patients were followed in our clinic prior to revision. The average time from primary surgery to revision for any reason was 29.6 months in our study for the 18.6% of primaries that needed revision. All surgeries were performed by either DGC or MSC at our center. Radiographic parameters were measured from preoperative, 1-year and 2-year follow-up radiographs. Coronal measures included Cobb angle and coronal C7 to center sacral vertical line (CSVL) distance. Sagittal measures included lateral C7 to sacrum distance, thoracic kyphosis (T5-T12), thoracolumbar kyphosis (T10-L2), and lumbar lordosis (T12 to sacrum). Clinical outcomes were assessed using the Oswestry disability index (ODI) and Visual analog pain (VAS) scores.23-24 Perioperative comorbidities and complications were also analyzed. Statistical analysis was conducted using SPSS software (SPSS Inc., Chicago, IL). Data were expressed as mean ± standard deviation and checked for normality and equal variances. Continuous variables were compared using the student t test. Dichotomous data such as incidence of complications were compared using the χ2 test or Fisher exact test depending on the frequency of outcomes. Clinical outcomes between preoperative and final follow-up for each group were compared using paired t-test. A two-tailed P value of less than 0.05 was considered statistically significant.
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Results Forty-five adult scoliosis patients undergoing revision surgery (35 women and 10
men) were included in this study, with 14 adult idiopathic scoliosis patients (12 women and 2 men) and 31 degenerative scoliosis patients (23 women and 8 men). The mean age was 62.7 ± 9.3 years (range, 46-79 years). The average height was 164.7 ± 10.2 cm (range, 147.3-190.5 cm) and the average weight was 76.0 ± 19.9 kg (range, 46.3-119.3 kg). The average BMI for this cohort was 27.8 ± 5.9 kg/m2 (range, 17.7-44.6 kg/m2). Table 1 shows the descriptive characteristics of the patients between the 2 groups: overweight (n = 27) and non-overweight (n = 18). Of note, 60% of the patients in this cohort (27 of 45) were found to be overweight, and 40% of the patients in this cohort (18 of 45) were non-overweight. As expected, patients in the overweight group had a significantly greater average weight and BMI than the non-overweight group (P < 0.001). Concomitant Comorbidities Table 1 shows the pre-existing comorbidities between the 2 different BMI groups. No significant difference existed with respect to bowel or bladder symptoms, cancer, depression/memory problems, heart disease, pulmonary problems, gastrointestinal problems, and hypertension between the 2 groups. However, 9 patients (33.3%) in the overweight group had peripheral vascular disorders while none in the non-overweight group had circulatory disorders (P = 0.018). In addition, diabetes showed a trend toward significant difference (P = 0.053) between overweight (25.9%, n = 7) and non-overweight (0%, n = 0) groups. Surgical methods Table 2 shows the surgical data of the 2 groups. The overweight group had similar posterior spinal fusion (PSF) levels as the non-overweight group (9.1 ± 2.9 vs. 8.4 ± 3.0, P = 0.462). Transforaminal lumbar interbody fusion (TLIF) levels (1.9 ± 0.7 vs. 2.0 ± 0.9, P = 0.729) and anterior lumbar interbody fusion (ALIF) levels (3.9 ± 1.5 vs. 4.7 ± 2.8, P = 0.451) were also similar. In the overweight group, Ponte/Smith-Peterson osteotomy (SPO) was performed on 14 patients (51.9%) and 3 patients needed pedicle
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subtraction osteotomy (PSO) (11.1%). This is comparable to the non-overweight group, in which SPOs were performed on 12 patients (66.7%) and 1 patient required a PSO (5.6%). The utilization of autograft, allograft, S2 screws, iliac screws, and sacral fixation was similar between the 2 groups. Radiographic data Major Cobb angle Table 3 shows the radiographic data of the 2 groups. The major Cobb angle was similar between the 2 groups (37.3º ± 18.0º vs. 39.8º ±11.8º, P = 0.727) at pre-op as well as 1-year follow-up (22.7º ± 16.9º vs. 16.5º ± 13.5º, P = 0.369). However, major curve change showed a trend toward significant difference between the overweight (14.6º ± 8.8º) and non-overweight (23.3º ± 13.0º) groups (P = 0.056) at 1-year follow-up. Thoracic kyphosis Overweight patients had a significantly greater preoperative thoracic kyphosis than non-overweight patients (39.0º ± 13.2º vs. 18.6º ± 11.7º, P = 0.044). This attribute remained unchanged by surgical intervention and was still significant at final follow-up (43.3º ± 9.1º vs. 23.3º ± 10.3º, P = 0.027). The mean change of thoracic kyphosis between overweight and non-overweight groups was similar and of no significant difference (P = 0.753). Lumbar lordosis and spinal balance Thoracolumbar alignment and lumbar lordosis showed no significant differences between the 2 groups at pre-op and final follow-up. The overweight group tended to have greater pre-operative coronal and sagittal imbalance than the non-overweight group, though these differences were not statistically significant (coronal: 4.9 ± 3.2 cm vs. 2.8 ± 3.6 cm, P = 0.225; sagittal: 8.1 ± 7.0 cm vs. 4.9 ± 6.2 cm, P = 0.401). The 2 groups had similar coronal and sagittal balance at final follow-up. Complications after revision surgery One (3.7%) patient in the overweight group and one patient (5.6%) in the non-overweight group developed a non-union. There were no significant differences between the 2 groups in terms of adjacent segment degeneration, junctional failure, or
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rod breakage (Table 4). No seromas, dural tears, or cage subsidences were recorded in either group. Three patients in the overweight group experienced temporary postoperative foot drop which resolved spontaneously within 3 months. In the overweight group, one patient developed superficial wound infection which resolved without surgical intervention and 3 patients had screw failures. In contrast, no patients in the non-overweight had these problems, although this difference in complication rates did not reach statistical significance. As for deep wound infections, there was no significant difference between the 2 groups (P = 0.714). All 3 deep infections resolved after surgical irrigation and debridement and IV antibiotics. Additional revision surgery for reasons beyond simple I&D (such as non-union or rod breakage) was required in 18.5% of the patients (n = 5) in the overweight group and 38.9% of patients (n = 7) in the non-overweight group (P = 0.242). Clinical outcomes Overweight patients had significantly higher preoperative VAS scores than non-overweight patients (7.1 ± 1.7 vs. 5.2 ± 2.9, P = 0.031) (Table 5). However, by final follow-up, overweight patients had similar VAS scores to non-overweight patients (3.7 ± 2.7 vs. R = 3.3 ± 2.3, P = 0.646). There were no significant differences in ODI scores at any time point between the 2 groups. Scoliosis correction contributed to similar VAS (3.4 ± 3.5 vs. 1.9 ± 2.3, P = 0.213) and ODI (22.0% ± 17.1% vs. 17.1% ± 18.8%, P = 0.440) improvements in both groups. Importantly, compared with preoperative values both overweight and non-overweight patients showed significant improvements of all clinical outcome scores at final follow-up (P < 0.001).
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Discussion Revision surgery for an adult spinal deformity is technically challenging.
Pichelmann et al,7 in their study of 643 consecutive patients, reported that the revision rate for patients having a primary fusion for adult spinal deformity is 9.0%. Cho et al15 compared the demographics between primary and revision adult scoliosis patients and found that BMI was significantly greater in the revision group than the primary group (27.4 ± 6.2 vs. 25.5 ± 4.9, P = 0.0068). As the number of overweight individuals in the population continues to grow, it is important to understand the effect of body mass index on the surgical outcomes in revision adult scoliosis patients. To our knowledge, this is the first study to elucidate the effect of body mass index on surgical outcomes in revision adult scoliosis patients. In this cohort, revision adult scoliosis patients had an average BMI of 27.8 ± 5.9 kg/m2, which is comparable to Cho’s15 result (27.4 ± 6.2 kg/m2). Furthermore, results showed that overweight patients had a higher rate of concomitant circulatory disorders and diabetes than non-overweight patients, which is consistent with the epidemiologic findings of obese patients in the United States. In this study, BMI did not affect the surgical approach or technique chosen with respect to PSF, TLIF and ALIF. This finding is consistent with previous studies which examined the effect of body mass index on surgical approach in primary patients with adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS).20,25 These studies concluded that there was no significant differences between overweight and non-overweight patients in regards to utilization of posterior-only, anterior and posterior, or thoracoscopic approaches. In this study, body mass index did not affect the amount of coronal or sagittal balance correction achievable through surgery. The relatively small sample size of our cohort might have limited the ability to detect significant differences between the 2 groups. In addition, Chen20 found that coronal curve correction was similar between overweight and non-overweight individuals undergoing primary surgery for adult idiopathic scoliosis at 2-year follow-up.
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Another significant radiographic finding of this study is that overweight patients had greater thoracic kyphosis than non-overweight patients (Table 3), which may be due to the increased load on the spine from soft tissues. Similar results were reported by Upasani et al25 in AIS populations and by Chen et al20 in AdIS populations. They postulated that increased trunk mass may exert a compressive force on anterior vertebral growth plates, limiting their growth and resulting in relative posterior column growth and kyphosis.20,25 Several studies have shown increased complication rates after spinal fusion for degenerative conditions in obese and morbidly obese patients.17,19 In particular, wound complications are especially high, which may be related to more difficult exposure, dissection, retraction, and longer operative times.19 However, no significant difference in complications with respect to non union, adjacent segment disease, implant failure, foot drop, infection, or further revision was found in our study. This finding is more consistent with previous studies demonstrating equivalent complication rates between overweight and non-overweight patients in AIS and AdIS.20,25 The difference in postoperative complication rates between obese degenerative lumbar arthrodesis patients and overweight scoliotic patients may be due to the longer incisions in deformity surgery allowing for much more adequate exposure and dissection compared to the smaller incisions in degenerative surgery, where the depth of the wound relative to incision length may have a greater impact. The role of BMI on
clinical
outcomes
in
spine surgery remains
controversial.17-20,25-28 Several studies report that obese patients may achieve similar benefit to non-obese patients.25,26 The Spine Patient Outcomes Research Trial (SPORT) 27
from 11 states across the United States demonstrated that obesity did not affect the
clinical outcome scores of surgery for lumbar stenosis and degenerative spondylolisthesis in terms of ODI and 36-Item Short Form Health Survey (SF-36) at 4-year follow-up. However, a recent study from the Swedish Spine Register with 2633 patients treated for lumbar spinal stenosis drew a different conclusion.18 Results showed that the obese group demonstrated inferior function and quality of life as measured by ODI and the EuroQol Group Index (EQ-5D) at 2-year follow-up.18
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Although significantly higher preoperative VAS scores were found in the overweight group, the amount of VAS improvement from pre-op to final follow-up was similar between the 2 groups. In addition, the perioperative improvement of ODI scores was also comparable between the 2 groups. Both overweight and non-overweight patients in our study improved significantly in terms of ODI and VAS scores at 2-year follow-up. Our data therefore demonstrates that overweight patients can benefit from surgical correction of revision adult scoliosis just as much as non-overweight patients, despite a higher pre-op VAS score. Unlike VAS and ODI scores, most radiographic parameters were not significantly different between the 2 groups either pre- or post-revision surgery. One limitation of our study is that the relatively small number of our cohort made it impossible for us to divide the patients into more finely stratified BMI groups such as morbidly obese, severely obese, obese, overweight and normal weight, though doing so would obviously be of additional value. Further studies are needed to elucidate the effect of morbid obesity on revision adult scoliosis surgery and longer post-operative follow-up is always desirable.
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Conclusion Overweight patients undergoing revision adult scoliosis achieved the same
coronal and sagittal balance as non-overweight patients, although they tended to have inferior coronal curve correction. Acknowledgements: The first author was supported by the Selecting and Training Outstanding Young Teachers in Shanghai Universities (Grant no. jdy08068), the National Nature Science Foundation of China (Grant no. 81201424), and the Projects of Shanghai Municipal Health Bureau (Grant no. 2012332).
Key points
Revision adult scoliosis surgery achieved the same coronal and sagittal balance in overweight patients as non-overweight patients, although coronal curve corrections tended to be inferior in obese individuals.
Overweight patients have significantly higher thoracic kyphosis than non-overweight patients both before and after surgery.
Despite having higher rates of circulatory disorders and diabetes, the overall clinical outcomes and complication rates of surgery in overweight patients are equivalent to those of normal weight.
Overweight patients benefited from surgery just as much as non-overweight patients at 2-year follow-up.
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Table 1. Characteristics of Overweight and Non-overweight Revision Adult Scoliosis Patients. Overweight
Non-overweight
P
27 (60%)
18 (40%)
―
Males
7 (25.9%)
3 (16.7%)
0.714
Females
20 (74.1%)
15 (83.3%)
―
Age (Year)
62.0 ± 8.6
63.8 ± 10.4
0.534
Height (cm)
165.5 ± 11.4
163.6 ± 8.2
0.898
Weight (kg)*
85.7 ± 18.9
60.6 ± 8.7
< 0.000
BMI (kg/m2)*
31.1 ± 5.1
22.6 ± 2.2
< 0.000
Bowel or bladder symptoms
7 (25.9%)
3 (16.7%)
0.714
Cancer
3 (11.1%)
1 (5.6%)
0.915
Circulation disorders*
9 (33.3%)
0 (0%)
0.018
Heat disease
4 (14.8%)
2 (11.1%)
0.929
Depression/Memory problems
4 (14.8%)
4 (22.2%)
0.811
Diabetes
7 (25.9%)
0 (0%)
0.053
Gastrointestinal problems
6 (22.2%)
3 (16.7%)
0.939
Hypertension
17 (63.0%)
7 (38.9%)
0.113
Pulmonary
6 (22.2%)
2 (11.1%)
0.577
No. patients Gender
*Significant difference (P