Abstract
Aims & objectives
Sagittal imbalance linked to adult spinal deformity negatively affects quality of life and can be treated with 3CO techniques. While effective, these methods are invasive and can lead to high complications. Since 2010, a more patient-focused approach has grown in popularity, but its effects on elderly patients remain unclear. This retrospective study aimed to investigate the trend of three-column osteotomy (3CO) utilization in posterior long-segment fusion among different age groups. We also sought to determine the safety profile of 3CO by analyzing postoperative complications in the elderly population.
Materials & methods
The study assessed postoperative complications and long-term outcomes for elderly patients aged 70 and above who underwent 3CO as part of a posterior spinal instrumented fusion from 2010 to 2020 using multivariable logistic regression. A total of 2091 patients were identified for analysis.
Results
The Mann-Kendall trend test revealed a significant downward trend in 3CO interventions after 2017. Elderly patients demonstrated higher rates of medical complications compared to younger cohorts but had lower rates of surgical complications and reoperations. This pattern persisted even after adjusting for baseline comorbidity profiles. At the five-year mark, elderly patients (ages 70–84) exhibited reoperation rates similar to the middle-aged group (ages 55–69) but notably lower than those in patients younger than 55 years.
Conclusion
Aside from an increased risk of medical complications following 3CO, older patients were not at an increased risk of surgical complications, including pseudarthrosis, proximal junctional failure, and reoperation.
Keywords: Reoperation, Retrospective studies, Postoperative complications, Aged, Adult spinal deformity, Three-column osteotomy
1. Introduction
The negative impact of sagittal imbalance on health-related quality of life (HRQOL) is becoming increasingly apparent. It is commonly associated with adult spinal deformity (ASD) and other etiologies, such as post-traumatic kyphosis and iatrogenic flatback syndrome following segmental instrumentation.1,2 The goals of ASD surgery are to alleviate pain, prevent deformity progression, and improve function.3 In some cases, rigid ASD often requires the use of three-column osteotomy (3CO) techniques such as pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR), which involve osteotomies from the posterior column extending into the anterior column, or anterior half of the vertebral body, to achieve sufficient correction.4, 5, 6, 7 Despite the variety of techniques, 3CO permits a significant correction of fixed spinal deformity in the sagittal, coronal, and axial planes simultaneously via a posterior-only approach.4,8, 9, 10
In older patients, spinal alignment and deformity are recognized as key determinants in pain and functional outcomes. In fact, after ASD correction, elderly patients experience significant improvements in pain and disability.11 In addition, even though elderly patients with ASD frequently present with greater dysfunction and lower HRQOL scores than younger patients, they are able to achieve substantial improvement after the surgery, resulting in postoperative outcomes comparable to those of younger patients.12
While 3CO is highly effective at restoring alignment, it carries a high risk of postoperative complications, ranging in 40 %–60 % of cases.4,6,13,14 This technique may be losing favor due to its complexity, invasiveness, inherent risks including high rate of pseudarthrosis.15 Since 2010, a patient-centered approach to achieving optimal realignment goals in ASD surgery, including the development of age-adjusted criteria that states overcorrection in elderly patients can lead to higher incidences of proximal junctional kyphosis and failure, has grown in popularity.16 These new concepts often help in better patient selection, potentially reducing the need for invasive procedures like 3CO for a number of patients.
A few studies have documented the impact of age in geriatric populations following 3COs, with most being single-center/single-surgeon retrospective reviews with a greater focus on radiographic parameters.17, 18, 19 The available literature does not provide a clear consensus of complications in older patients compared to younger patients after undergoing 3CO. In the present study, we investigated the role of age in the development of postoperative complications for ASD patients who underwent a 3CO, as well as trends in utilization using a large national database.
2. Materials and methods
2.1. Data source
This retrospective database review was performed using the commercially available PearlDiver (PearlDiver Inc., Colorado Springs, Colorado, USA; www.pearldiverinc.com) patient records database. The database contains all Mariner private payer, Medicare, and Medicaid patient records for the years 2010–October 2021, searchable by International Classification of Diseases (ICD) 9th and 10th Edition codes as well as by Current Procedural Terminology (CPT) codes. This study was deemed exempt from institutional review board approval, as all queried data was deidentified and Health Insurance Portability and Accountability Act (HIPAA) compliant.
2.2. Study population
Patients who underwent posterior instrumented fusion (≥6 levels) (CPT-22802, CPT-22843, CPT-22804, CPT-22844) and pelvic fixation (CPT-22848) with 3CO (CPT-22206, CPT-22207) from 2010 to 2020 were included. Cases involving multiple level 3COs (CPT-22208) were excluded. Patients who presented with, or had a 90-day history of spinal infection, trauma, or neoplasm were excluded from the study. In addition, patients without a full two-year follow up were excluded. Patients were then separated into three groups by age: older (70–84), middle age (55–69), younger (<55). Baseline comorbidities were assessed with Charlson Comorbidity Index (CCI), obesity (BMI 30–40 and BMI 40+), chronic kidney disease, diabetes mellitus, smoking, depression, and osteoporosis. Surgical parameters included 3CO region (thoracic or lumbar), number of instrumented levels, use of anterior cage, percentage of staged anterior surgery, and prior fusion.
2.3. Outcomes of interest
90-day medical complications included cardiopulmonary, central nervous system, gastrointestinal, renal, and infectious. 90-day surgical complications included dural tear, nerve root injury, vascular injury, visceral injury, transfusion, neurological deficit, and wound-related complications. 2-year complications included instrumentation pain/prominence and failure, pseudarthrosis, proximal junctional failure (PJF), pelvic fixation failure (PFF), and reoperation. PJF was defined as any revision of instrumentation extension proximally. PFF was defined as any revision to pelvic screws due to rod fractures, pseudarthrosis at the lumbosacral junction, broken or loose screws, or sacral/iliac fractures.20 90-day emergency department (ED) visits, readmission, and mortality were also documented.
2.4. Statistical analysis
Mann-Kendall trend test was used to analyze trends in utilization of 3CO stratified by age group from 2010 to 2021. Pearson χ2 test was used to assess for differences in demographics, preexisting comorbidities, and surgical details. Multivariable logistic regression was used to determine the effects of old age (≥70) on the postoperative outcomes after adjusting for surgical parameters. In addition, an exact match based on comorbidities was executed among all groups in an effort to assess the independent impact of old age alone on overall complications. Kaplan-Meier survival plots were produced for reoperations at 5 years and compared using a log rank test. All statistical analyses were conducted using the research query interface provided by PearlDiver Bellwether. The common statistical metrics, including frequencies, mean values, and odds ratios (ORs), were collected by the Bellwether system using the R statistical package. Statistical significance was set at p < 0.05.
3. Results
3.1. Trends
The Mann-Kendall trend test confirmed a significant decrease in 3CO intervention after 2017 in all 3 age groups undergoing deformity correction (p < 0.001) (Fig. 1).
Fig. 1.
Frequency of three-column osteotomy utilization in posterior spinal instrumented fusion from 2010 to 2021 by age groups.
3.2. Patient demographics
A total of 2091 patients undergoing posterior spinal instrumented fusion with 3CO were identified within the time period of interest. Older patients (70–84 years) had the highest CCI scores (2.1 ± 2.1), in contrast to the younger group (<55 years) with lower scores (1.3 ± 1.4) (p < 0.001). Middle-aged patients (55–69 years) exhibited intermediate CCI scores (1.9 ± 2.1). Other comorbidities differed significantly among the groups (p < 0.05). Surgically, the number of instrumented levels greater than 11 differed significantly with 21.7 % in the older, 28.4 % in the middle-aged, and 28.5 % in the younger patients (p = 0.008) (Table 1).
Table 1.
Summary of demographic, comorbidity, and surgical data of 2091 adult spinal deformity patients undergoing 3CO with a minimum of 2-year follow-up.
| Older 70-84 n = 576 |
Middle Age 55-69 n = 1213 |
Younger <55 n = 302 |
p-value | |||||
|---|---|---|---|---|---|---|---|---|
| Sex (female) | 194 | 33.7 % | 399 | 32.9 % | 108 | 35.8 % | 0.637 | |
| Comorbidities | ||||||||
| CCI | 2.1 ± 2.1 | 1.9 ± 2.1 | 1.3 ± 1.4 | <0.001∗ | ||||
| BMI 30-40 | 71 | 12.3 % | 134 | 11.0 % | 35 | 11.6 % | 0.729 | |
| BMI 40+ | 23 | 4.0 % | 57 | 4.7 % | 35 | 11.6 % | <0.001∗ | |
| Smoke | 72 | 12.5 % | 269 | 22.2 % | 77 | 25.5 % | <0.001∗ | |
| Diabetes mellitus | 216 | 37.5 % | 363 | 29.9 % | 48 | 15.9 % | <0.001∗ | |
| Chronic kidney disease | 98 | 17.0 % | 125 | 10.3 % | 17 | 5.6 % | <0.001∗ | |
| Depression | 143 | 24.8 % | 450 | 37.1 % | 120 | 39.7 % | <0.001∗ | |
| Osteoporosis | 62 | 10.8 % | 95 | 7.8 % | 14 | 4.6 % | 0.002∗ | |
| Surgical parameters | ||||||||
| Osteotomy Region | Thoracic | 35 | 6.1 % | 81 | 6.7 % | 27 | 8.9 % | 0.263 |
| Lumbar | 543 | 94.3 % | 1133 | 93.4 % | 275 | 91.1 % | 0.190 | |
| No. of instrumented levels | ≤11 | 453 | 78.6 % | 869 | 71.6 % | 216 | 71.5 % | 0.005∗ |
| >11 | 125 | 21.7 % | 345 | 28.4 % | 86 | 28.5 % | 0.008∗ | |
| Anterior cage | 79 | 13.7 % | 163 | 13.4 % | 48 | 15.9 % | 0.071 | |
| Staged surgery | 30 | 5.2 % | 72 | 5.9 % | 21 | 7.0 % | 0.576 | |
| Previous fusion | 185 | 32.1 % | 401 | 33.1 % | 102 | 33.8 % | 0.870 | |
3CO, Three-column osteotomy; CCI, Charlson Comorbidity Index; BMI, Body Mass Index.
Boldface type indicates statistical significance with p < 0.05.
3.3. Postoperative complications
Older adults experienced arrhythmias more frequently at 17.7 % than middle-aged and younger patients, who had rates of 12.1 % (p = 0.001) and 9.9 % (p = 0.002), respectively. Myocardial infarction was also notably higher in the older group at 4.5 % compared to middle-aged and younger patients, with occurrences at 2.2 % (p = 0.009) and 1.0 % (p = 0.011), respectively. Cerebrovascular accidents were present in 2.4 % of older patients, which was significantly higher than middle-aged patients at 0.7 % (p = 0.003) and younger patients who reported no events. The incidence of electrolyte abnormalities was greater in older adults at 7.8 %, compared to 4.7 % in middle-aged patients (p = 0.011) and 4.0 % in younger patients (p = 0.040). Older patients also had higher rates of renal failure at 7.8 % compared to younger patients only at 2.6 % (p = 0.004). Finally, the older age group had a higher rate of urinary tract infection at 15.5 %, compared to 11.8 % in the middle-aged group (p = 0.038) and 9.9 % in the younger cohort (p = 0.030) (Table 2).
Table 2.
Comparative analysis of 90-day medical complications for 3 age groups following 3CO.
| Older 70-84 n = 576 |
Middle Age 55-69 n = 1213 |
Younger <55 n = 302 |
Older vs. Middle Age OR (95 % CI) | Older vs. Younger OR (95 % CI) | Older vs. Middle Age p-value | Older vs. Younger p-value | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Cardiopulmonary | ||||||||||
| Arrhythmia | 102 | 17.7 % | 147 | 12.1 % | 30 | 9.9 % | 1.56 (1.19–2.03) | 1.96 (1.26–3.01) | 0.001∗ | 0.002∗ |
| Myocardial infarction | 26 | 4.5 % | 27 | 2.2 % | 3 | 1.0 % | 2.04 (1.19–3.48) | 4.67 (1.38–15.76) | 0.009∗ | 0.011∗ |
| Cardiac arrest | 8 | 1.4 % | 8 | 0.7 % | 0 | 0.0 % | 2.12 (0.79–5.68) | – | 0.207 | 0.092 |
| Atelectasis | 104 | 18.1 % | 210 | 17.3 % | 50 | 16.6 % | 1.05 (0.81–1.36) | 1.11 (0.77–1.61) | 0.749 | 0.644 |
| Respiratory failure | 72 | 12.5 % | 147 | 12.1 % | 33 | 10.9 % | 1.04 (0.77–1.40) | 1.16 (0.75–1.80) | 0.879 | 0.567 |
| Pleural effusion | 63 | 10.9 % | 120 | 9.9 % | 27 | 8.9 % | 1.12 (0.81–1.54) | 1.25 (0.78–2.01) | 0.550 | 0.418 |
| PE | 9 | 1.6 % | 23 | 1.9 % | 5 | 1.7 % | 0.84 (0.43–1.65) | 0.94 (0.31–2.83) | 0.733 | 0.916 |
| DVT | 12 | 2.1 % | 30 | 2.5 % | 9 | 3.0 % | 0.84 (0.43–1.65) | 0.69 (0.29–1.66) | 0.733 | 0.553 |
| Central Nervous System | ||||||||||
| CVA | 14 | 2.4 % | 8 | 0.7 % | 0 | 0.0 % | 3.75 (1.57–9.00) | – | 0.003∗ | – |
| Delirium | 18 | 3.1 % | 32 | 2.6 % | 0 | 0.0 % | 1.19 (0.66–2.14) | – | 0.667 | – |
| Gastrointestinal | ||||||||||
| Ileus | 30 | 5.2 % | 59 | 4.9 % | 12 | 4.0 % | 1.07 (0.68–1.69) | 1.33 (0.67–2.63) | 0.844 | 0.517 |
| Bowel Obstruction | 5 | 0.9 % | 8 | 0.7 % | 0 | 0.0 % | 1.32 (0.43–4.05) | – | 0.851 | – |
| Renal | ||||||||||
| Electrolyte abnormality | 45 | 7.8 % | 57 | 4.7 % | 12 | 4.0 % | 1.72 (1.15–2.57) | 2.05 (1.07–3.93) | 0.011∗ | 0.040∗ |
| Renal failure | 45 | 7.8 % | 68 | 5.6 % | 8 | 2.6 % | 1.43 (0.97–2.11) | 3.11 (1.45–6.70) | 0.091 | 0.004∗ |
| Urinary retention | 47 | 8.2 % | 77 | 6.3 % | 18 | 6.0 % | 1.31 (0.90–1.91) | 1.40 (0.80–2.46) | 0.190 | 0.295 |
| Infectious | ||||||||||
| Pneumonia | 41 | 7.1 % | 68 | 5.6 % | 14 | 4.6 % | 1.29 (0.86–1.93) | 1.58 (0.85–2.94) | 0.253 | 0.195 |
| Sepsis | 18 | 3.1 % | 35 | 2.9 % | 5 | 1.7 % | 1.09 (0.61–1.93) | 1.92 (0.70–5.21) | 0.897 | 0.283 |
| UTI | 89 | 15.5 % | 143 | 11.8 % | 30 | 9.9 % | 1.37 (1.03–1.82) | 1.66 (1.07–2.57) | 0.038∗ | 0.030∗ |
PE, Pulmonary embolism; DVT, Deep vein thrombosis; CVA, Cerebrovascular accident; UTI, Urinary tract infection.
Boldface type indicates statistical significance with p < 0.05.
For surgical complications, older adults had a lower transfusion rate at 2.4 %, compared to 5.6 % in younger patients (p = 0.025). The incidence of seroma was higher in older patients at 2.4 % compared to middle-aged patients at 0.7 % (p = 0.003). At the 2-year follow-up for mechanical/structural complications, instrumentation failure was reported in 9.2 % of older patients, versus 11.9 % in middle-aged and 15.6 % in younger patients, with older patients experiencing a significantly lower rate compared to younger patients (p = 0.007). Pseudarthrosis was noted in 13.4 % of older adults, compared to 16.6 % in middle-aged and 15.9 % in younger patients, but these differences were not statistically significant. Older patients had the lowest rate of pelvic fixation failure at 1.6 % compared to younger cohorts at 4.0 % (p = 0.034). Reoperation rates in older adults were 19.3 %, which was significantly lower than reoperation rates in younger patients at 29.8 % (p = 0.001) (Table 3).
Table 3.
Comparative analysis of 90-day and 2-year surgical complications for 3 age groups following 3CO.
| Older 70-84 n = 576 |
Middle Age 55-69 n = 1213 |
Younger <55 n = 302 |
Older vs. Middle Age OR (95 % CI) | Older vs. Younger OR (95 % CI) | Older vs. Middle Age p-value | Older vs. Younger p-value | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Operative | ||||||||||
| Dural tear | 36 | 6.3 % | 68 | 5.6 % | 18 | 6.0 % | 1.12 (0.74–1.70) | 1.05 (0.59–1.89) | 0.663 | 0.983 |
| Nerve root injury | 11 | 1.9 % | 23 | 1.9 % | 6 | 2.0 % | 1.01 (0.49–2.08) | 0.96 (0.35–2.62) | 0.928 | 0.934 |
| Vascular injury | 3 | 0.5 % | 9 | 0.7 % | 2 | 0.7 % | 0.70 (0.19–2.60) | 0.79 (0.13–4.73) | 0.822 | 0.837 |
| Visceral injury | 2 | 0.3 % | 3 | 0.2 % | 0 | 0.0 % | 1.41 (0.23–8.43) | – | 0.978 | – |
| Transfusion | 14 | 2.4 % | 26 | 2.1 % | 17 | 5.6 % | 1.14 (0.59–2.19) | 0.42 (0.20–0.86) | 0.832 | 0.025∗ |
| Neurological | ||||||||||
| Nerve root motor deficit | 53 | 9.2 % | 89 | 7.3 % | 23 | 7.6 % | 1.28 (0.90–1.83) | 1.23 (0.74–2.05) | 0.204 | 0.505 |
| Nerve root sensory deficit | 14 | 2.4 % | 27 | 2.2 % | 8 | 2.6 % | 1.09 (0.57–2.10) | 0.92 (0.38–2.21) | 0.919 | 0.876 |
| Radiculopathy | 24 | 4.2 % | 59 | 4.9 % | 12 | 4.0 % | 0.85 (0.52–1.38) | 1.05 (0.52–2.13) | 0.593 | 0.834 |
| Spinal cord deficit | 9 | 1.6 % | 21 | 1.7 % | 8 | 2.6 % | 0.90 (0.41–1.98) | 0.58 (0.22–1.53) | 0.950 | 0.394 |
| Cauda equina deficit | 5 | 0.9 % | 5 | 0.4 % | 0 | 0.0 % | 2.12 (0.61–7.34) | – | 0.385 | – |
| Wound/SSI | ||||||||||
| Wound dehiscence | 44 | 7.6 % | 71 | 5.9 % | 14 | 4.6 % | 1.33 (0.90–1.96) | 1.70 (0.92–3.16) | 0.182 | 0.119 |
| Seroma | 14 | 2.4 % | 8 | 0.7 % | 2 | 0.7 % | 3.75 (1.57–9.00) | 3.74 (0.84–16.55) | 0.003∗ | 0.111 |
| Hematoma | 9 | 1.6 % | 14 | 1.2 % | 5 | 1.7 % | 1.36 (0.58–3.16) | 0.94 (0.31–2.84) | 0.623 | 0.846 |
| Deep wound infection | 48 | 8.3 % | 104 | 8.6 % | 27 | 8.9 % | 0.97 (0.68–1.39) | 0.93 (0.57–1.52) | 0.936 | 0.858 |
| Superficial wound infection | 9 | 1.6 % | 17 | 1.4 % | 5 | 1.7 % | 1.12 (0.49–2.52) | 0.94 (0.31–2.84) | 0.957 | 0.879 |
| Mechanical/Structural (2y) | ||||||||||
| Instrumentation painful/prominent | 27 | 4.7 % | 66 | 5.4 % | 14 | 4.6 % | 0.85 (0.54–1.35) | 1.01 (0.52–1.96) | 0.578 | 0.874 |
| Instrumentation failure | 53 | 9.2 % | 144 | 11.9 % | 47 | 15.6 % | 0.75 (0.54–1.05) | 0.55 (0.36–0.84) | 0.109 | 0.007∗ |
| Pseudarthrosis | 77 | 13.4 % | 201 | 16.6 % | 48 | 15.9 % | 0.78 (0.59–1.03) | 0.82 (0.55–1.21) | 0.094 | 0.360 |
| PJF | 27 | 4.7 % | 45 | 3.7 % | 12 | 4.0 % | 1.28 (0.78–2.08) | 1.19 (0.59–2.38) | 0.393 | 0.752 |
| Pelvic fixation failure | 9 | 1.6 % | 38 | 3.2 % | 12 | 4.0 % | 0.49 (0.23–1.02) | 0.40 (0.16–0.93) | 0.058 | 0.034∗ |
| Reoperation | 111 | 19.3 % | 267 | 22.0 % | 90 | 29.8 % | 0.85 (0.66–1.08) | 0.56 (0.41–0.78) | 0.206 | 0.001∗ |
SSI, Surgical site infection; PJF, Proximal junctional failure.
Boldface type indicates statistical significance with p < 0.05.
Older patients were less likely to visit the ED within 90 days at 16.8 % compared to younger patients at 24.5 % (p = 0.008). They were also less likely to be readmitted within 90 days at 13.7 % compared to younger patients at 19.5 % (p = 0.031). Additionally, 90-day mortality was significantly higher in older patients at 3.1 % compared to middle-aged patients at 1.5 % (p = 0.033) and younger patients at 0.7 % (p = 0.037) (Table 4).
Table 4.
Comparative analysis of 90-day postoperative healthcare outcomes for 3 age groups following 3CO.
| Older 70-84 n = 576 |
Middle Age 55-69 n = 1213 |
Younger <55 n = 302 |
Older vs. Middle Age OR (95 % CI) | Older vs. Younger OR (95 % CI) | Older vs. Middle Age p-value | Older vs. Younger p-value | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| ED visit | 97 | 16.8 % | 187 | 15.4 % | 74 | 24.5 % | 1.11 (0.85–1.45) | 0.62 (0.44–0.88) | 0.483 | 0.008∗ |
| Hospital readmission | 79 | 13.7 % | 176 | 14.5 % | 59 | 19.5 % | 0.94 (0.70–1.25) | 0.65 (0.45–0.95) | 0.706 | 0.031∗ |
| Mortality | 18 | 3.1 % | 18 | 1.5 % | 2 | 0.7 % | 2.14 (1.11–4.15) | 4.84 (1.12–20.99) | 0.033∗ | 0.037∗ |
ED, Emergency department.
Boldface type indicates statistical significance with p < 0.05.
A comparative analysis was carried out matching for CCI and other comorbidities. Older adults experienced any medical complication at a rate of 50.0 %, which was significantly higher than middle-aged patients, who had a rate of 39.9 % (p = 0.016). However, older adults had a lower incidence of any surgical complication (52.2 %) compared to younger patients (61.6 %), with the difference being statistically significant (p = 0.025) (Table 5).
Table 5.
Comparative Analysis of Complications for 3 Age Groups Matched for Comorbidities (CCI = 1.0 ± 1.2; p = 0.962) Following 3CO.
| Older 70-84 n = 276 |
Middle Age 55-69 n = 276 |
Younger <55 n = 276 |
Older vs. Middle Age OR (95 % CI) | Older vs. Younger OR (95 % CI) | Older vs. Middle Age p-value | Older vs. Younger p-value | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Any medical complication (# of affected patients) | 138 | 50.0 % | 110 | 39.9 % | 128 | 46.4 % | 1.51 (1.07–2.11) | 1.15 (0.82–1.61) | 0.016∗ | 0.394 |
| Total number of medical complications | 286 | – | 230 | – | 268 | – | – | – | – | – |
| Any surgical complication (# of affected patients) | 144 | 52.2 % | 148 | 53.6 % | 170 | 61.6 % | 0.94 (0.67–1.31) | 0.68 (0.48–0.95) | 0.733 | 0.025∗ |
| Total number of surgical complications | 226 | – | 260 | – | 314 | – | – | – | – | – |
Boldface type indicates statistical significance with p < 0.05.
Patients were then tracked up to 5 years. By that time, due to the requirement for a minimum of 5-year follow-up post-surgery for additional subgroup analysis, only patients who had their surgery before November 2016 could be included. This resulted in 367 older patients, 763 middle-aged patients, and 222 younger patients remaining in the dataset. There were 88 reoperations in older patients at 23.9 %, 232 reoperations in middle-aged patients at 30.4 % (p = 0.037), and 77 reoperations in younger patients at 33.8 % (p = 0.009). Log rank test revealed a statistical difference between the rate of reoperation-free survival in the three groups (p = 0.042) (Fig. 2).
Fig. 2.
Kaplan-Meier plot showing 5-year revision-free survival following posterior spinal instrumented fusion with three-column osteotomy in 3 age groups (p = 0.042). Colored areas indicate 95 % confidence interval.
4. Discussion
4.1. Key results
Despite the decline in 3CO usage since 2017 as shown in Fig. 1, the 3CO continues to play an essential role in certain instances of ASD surgery. For most patients with ASD, thoracolumbar deformity is semiflexible and can be treated effectively with posterior column osteotomies or anterior column release.21,22 However, the more invasive 3CO may be necessary to achieve adequate correction in cases of rigid, fixed, kyphotic deformity, flat-back syndrome, and severe ankylosing spondylitis, among other conditions.23, 24, 25 The disadvantages of 3CO are the high risks of major complications, neurological injury, and substantial blood loss.14,26, 27, 28 As life expectancy continues to rise, more elderly patients are presenting with symptomatic ASD.29,30 Therefore, it raises the question of whether elderly patients can tolerate 3CO. Understanding the significance of how old age affects morbidity in the postoperative period will aid surgeons in counseling and selecting appropriate surgical candidates.
In the literature, it is commonly accepted that older patients are more likely to experience medical complications. Lee et al. conducted a retrospective study of 1591 patients to identify risk factors for medical complications and mortality following general spine surgery.31 They identified that age greater than 65 was a significant risk factor for complications involving five of six organ systems (cardiac, pulmonary, gastrointestinal, neurological, and hematological). Even in the case of ASD, older age has been linked to increased morbidity and has been identified as a risk factor for all types of complications, particularly renal injuries, and urinary tract infections. Daubs et al. found that age over 69 years and having a lumbar PSO were predictors for major complications, including myocardial infarction.32 Similarly, Bridwell et al. found that 24 out of 27 patients, aged 60 and up, who underwent lumbar PSO for sagittal imbalance experienced serious complications, including 1 case of myocardial infarction.6 In a large single-surgeon cohort analysis of 300 3CO cases, Lau et al. concluded that age is associated with higher rates of medical complications.17 Similar to previous findings, we observed higher rates of medical complications such as myocardial infarction, stroke, acute kidney injury, and urinary tract infarction in older patients above the age of 70.
Surgical outcomes in the elderly ASD population are inconsistent in the published literature. Some studies found older patients are at an increased risk of vertebral subluxation, malalignment reoccurrence, inadequate correction, and sagittal decompensation following 3CO due to rigid deformities.33, 34, 35 Lee et al. reported the incidence of rod fracture to be 42 % of patients with a mean age of 70.8 undergoing PSO within 2 years.18 Smith et al. reported the rod fracture occurred in 22 % of PSO patients and that patients with rod fracture were older (62.3 vs 54.1 years).36 For young patients, Qian et al. did not note any instrument related complications within 1 year in a cohort of 310 PSO patients with a mean age of 35.4 and found that PSO did not increase the risk of complications compared to Smith-Petersen osteotomy.19 Nevertheless, our results challenge the findings of the existing literature. Instrumentation failure was less common in older patients at 9.2 % compared to younger patients at 15.6 %. Additionally, the total reoperation rate at postoperative year 2 was lower in older patients at 19.3 % compared to younger patients at 29.8 %. The differences between older patients and middle-aged patients were not significant, though older patients displayed reduced rates.
It is possible that older patients generally have less active lifestyles compared to younger patients, resulting in less mechanical stress on the implant and reducing the risk of instrument failure. On the contrary, younger age has been linked to a higher incidence of symptomatic pseudarthrosis.37 This may be related to higher physical demands on the implant and fusion site or higher expectations among younger patients, although the exact etiology is unclear.38 Furthermore, smoking has been recognized as a modifiable risk factor for pseudarthrosis and instrumentation failure in spine surgery. Grubb et al. identified a relative risk of 3.75 for pseudarthrosis among smokers versus nonsmokers in an adult scoliosis cohort.39 In addition, Dinizo et al. discovered that current smoking was associated with a 3-fold increased risk of pseudarthrosis or rod fracture in ASD patients.40 A meta-analysis revealed that smoking, along with construct length >12 levels, is an independent risk factor for ASD pseudarthrosis.41 In the present study, smoking prevalence and construct length >11 levels was lowest among older patients.
Our results also revealed that older patients had the lowest rate of PFF at 1.6 % compared to younger patients at 4.0 %. Martin et al. performed a retrospective review on 779 cases (169 cases of 3CO) and found no difference between age in patients with PFF and without, though 3CO was identified as a risk factor for PFF.42 Bourghli et al. conducted a systematic review that revealed enhanced stability of spinal constructs with the application of dual iliac screws versus single iliac screws, which is particularly beneficial for osteoporotic patients needing extensive fusion for ASD correction or those undergoing 3COs.43
Nevertheless, when treating elderly patients, it is important to carefully guide them through their postoperative course, taking into account the higher incidences of medical complications. Clearly, not all patients of the same age are in the same state of health or have the same physiological reserve, hence not all patients tolerate surgery in the same manner. The results of this study indicate that age alone is not a contraindication for 3CO. Identifying patients who are too ill or unable to tolerate deformity corrections remains essential. Instead of using subjective inclinations to determine a patient's surgical candidacy, surgeons should have access to a tool that accurately and objectively evaluates surgical risk.
4.2. Limitations & strengths
Unfortunately, there are inherent limitations to the use of a large retrospective database. The reliability of our findings depends on the precision of the database's coding. Human error can result in inaccurate coding; however, this error is estimated to account for only 1.1 % of all entries.44 Radiographic data could not be assessed and controlled for due to a lack of granularity in the database, prohibiting detailed analysis of radiographic parameters, which is a crucial part of evaluations in ASD. Younger patients could have more severe deformities, which may contribute to additional surgical complications. Other surgical details such as exact UIV level and osteotomy level, use of accessory rod, type of pelvic fixation, use of kickstand rod etc. prohibited a thorough analysis. Finally, without patient-reported outcomes, it is unclear if the lower reoperation rate in the elderly group is due to patients declining to undergo further surgical intervention.
5. Conclusion
To our knowledge, there are no studies that have focused on postoperative long-term outcomes, including reoperation rates, following 3CO in patients 70 years or older. The findings from this study suggest that patients in their 7th and 8th decade of life may be amenable for 3CO to treat thoracolumbar deformity. These findings may prove useful for treatment planning, patient counseling, complication rate benchmarking, and efforts to improve patient care safety.
CRediT authorship contribution statement
Ved A. Vengsarkar: Formal analysis, Writing – review & editing. Jialun Chi: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft. Kate S. Woods: Writing – review & editing. Hanzhi Yang: Writing – review & editing. Zhichang Zhang: Writing – review & editing. Yi Zhang: Writing – review & editing. Jesse Wang: Writing – review & editing. Lawal Labaran: Writing – review & editing. Xudong Li: Writing – review & editing, Supervision, Project administration.
Guardian/patient's consent
Due to the retrospective nature of the study, informed consent of the patients was not required because the study analyzed de-identified, anonymous clinical data.
Ethical considerations
This manuscript did not require approval from IRB, Research Ethics Committee, or local equivalent approval.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgements
No acknowledgements to report.
References
- 1.Eskilsson K., Sharma D., Johansson C., Hedlund R. Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome? J Neurosurg Spine. 2017;27:56–62. doi: 10.3171/2016.12.SPINE16585. [DOI] [PubMed] [Google Scholar]
- 2.Bridwell K.H., Lewis S.J., Edwards C., et al. Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine. 2003;28:2093. doi: 10.1097/01.BRS.0000090891.60232.70. [DOI] [PubMed] [Google Scholar]
- 3.Hassanzadeh H., Jain A., El Dafrawy M.H., et al. Three-column osteotomies in the treatment of spinal deformity in adult patients 60 years old and older: outcome and complications. Spine (Phila Pa 1976) 2013;38:726–731. doi: 10.1097/BRS.0b013e31827c2415. [DOI] [PubMed] [Google Scholar]
- 4.Dorward I.G., Lenke L.G. Osteotomies in the posterior-only treatment of complex adult spinal deformity: a comparative review. Neurosurg Focus. 2010;28:E4. doi: 10.3171/2009.12.FOCUS09259. [DOI] [PubMed] [Google Scholar]
- 5.Suk S.-I., Kim J.-H., Kim W.-J., Lee S.-M., Chung E.-R., Nah K.-H. Posterior vertebral column resection for severe spinal deformities. Spine (Phila Pa 1976) 2002;27:2374–2382. doi: 10.1097/00007632-200211010-00012. [DOI] [PubMed] [Google Scholar]
- 6.Bridwell K.H., Lewis S.J., Lenke L.G., Baldus C., Blanke K. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am. 2003;85:454–463. doi: 10.2106/00004623-200303000-00009. [DOI] [PubMed] [Google Scholar]
- 7.Bradford D.S., Tribus C.B. Vertebral column resection for the treatment of rigid coronal decompensation. Spine (Phila Pa 1976) 1997;22:1590–1599. doi: 10.1097/00007632-199707150-00013. [DOI] [PubMed] [Google Scholar]
- 8.Schwab F., Blondel B., Chay E., et al. The comprehensive anatomical spinal osteotomy classification. Neurosurgery. 2014;74:112–120. doi: 10.1227/NEU.0000000000000182o. discussion 120. [DOI] [PubMed] [Google Scholar]
- 9.Cho K.-J., Bridwell K.H., Lenke L.G., Berra A., Baldus C. Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine (Phila Pa 1976) 2005;30:2030–2037. doi: 10.1097/01.brs.0000179085.92998.ee. discussion 2038. [DOI] [PubMed] [Google Scholar]
- 10.Gill J.B., Levin A., Burd T., Longley M. Corrective osteotomies in spine surgery. J Bone Joint Surg Am. 2008;90:2509–2520. doi: 10.2106/JBJS.H.00081. [DOI] [PubMed] [Google Scholar]
- 11.Sciubba D.M., Scheer J.K., Yurter A., et al. International Spine Study Group (ISSG) Patients with spinal deformity over the age of 75: a retrospective analysis of operative versus non-operative management. Eur Spine J. 2016;25:2433–2441. doi: 10.1007/s00586-015-3759-7. [DOI] [PubMed] [Google Scholar]
- 12.Scheer J.K., Mundis G.M., Klineberg E., et al. International Spine Study Group (ISSG) Postoperative recovery after adult spinal deformity surgery: comparative analysis of age in 149 patients during 2-year follow-up. Spine. 2015;40:1505–1515. doi: 10.1097/BRS.0000000000001062. (Phila Pa 1976) [DOI] [PubMed] [Google Scholar]
- 13.Lenke L.G., Newton P.O., Sucato D.J., et al. Complications after 147 consecutive vertebral column resections for severe pediatric spinal deformity: a multicenter analysis. Spine (Phila Pa 1976) 2013;38:119–132. doi: 10.1097/BRS.0b013e318269fab1. [DOI] [PubMed] [Google Scholar]
- 14.Bianco K., Norton R., Schwab F., et al. International Spine Study Group Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus. 2014;36:E18. doi: 10.3171/2014.2.FOCUS1422. [DOI] [PubMed] [Google Scholar]
- 15.O'Neill K.R., Lenke L.G., Bridwell K.H., Neuman B.J., Kim H.J., Archer K.R. Factors associated with long-term patient-reported outcomes after three-column osteotomies. Spine J. 2015;15:2312–2318. doi: 10.1016/j.spinee.2015.06.044. [DOI] [PubMed] [Google Scholar]
- 16.Lafage R., Schwab F., Glassman S., et al. International Spine Study Group Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976) 2017;42:1275–1282. doi: 10.1097/BRS.0000000000002146. [DOI] [PubMed] [Google Scholar]
- 17.Lau D., Osorio J.A., Deviren V., Ames C.P. The relationship of older age and perioperative outcomes following thoracolumbar three-column osteotomy for adult spinal deformity: an analysis of 300 consecutive cases. J Neurosurg Spine. 2018;28:593–606. doi: 10.3171/2017.10.SPINE17374. [DOI] [PubMed] [Google Scholar]
- 18.Lee K.Y., Lee J.-H., Kang K.-C., Im S.-K., Lim H.S., Choi S.W. Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion. J Neurosurg Spine. 2021;34:706–715. doi: 10.3171/2020.8.SPINE201037. [DOI] [PubMed] [Google Scholar]
- 19.Qian B., Huang J., Qiu Y., et al. Complications of spinal osteotomy for thoracolumbar kyphosis secondary to ankylosing spondylitis in 342 patients: incidence and risk factors. J Neurosurg Spine. 2018;30:91–98. doi: 10.3171/2018.6.SPINE171277. [DOI] [PubMed] [Google Scholar]
- 20.Lee N.J., Marciano G., Puvanesarajah V., et al. Incidence, mechanism, and protective strategies for 2-year pelvic fixation failure after adult spinal deformity surgery with a minimum six-level fusion. J Neurosurg Spine. 2022;38:208–216. doi: 10.3171/2022.8.SPINE22755. [DOI] [PubMed] [Google Scholar]
- 21.Lui D.F., Butler J.S., Yu H.M., et al. Neurologic injury in complex adult spinal deformity surgery: staged multilevel oblique lumbar interbody fusion (MOLIF) using hyperlordotic tantalum cages and posterior fusion versus pedicle subtraction osteotomy (PSO) Spine (Phila Pa 1976) 2019;44:E939–E949. doi: 10.1097/BRS.0000000000003034. [DOI] [PubMed] [Google Scholar]
- 22.Chi J, Zhang Y, Fontaine A, Zhang Z, Wang J, Labaran L, Li X Pedicle Subtraction Osteotomy Versus Multilevel Anterior Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion in the Treatment of Adult Spinal Deformity: Trends, Outcomes, and Cost. Clinical Spine Surgery 10.1097/BSD.0000000000001566. 10.1097/BSD.0000000000001566. [DOI] [PubMed]
- 23.Lau D., Haddad A.F., Fury M.T., Deviren V., Ames C.P. Multilevel pedicle subtraction osteotomy for correction of severe rigid adult spinal deformities: a case series, indications, considerations, and literature review. Oper Neurosurg (Hagerstown) 2021;20:343–354. doi: 10.1093/ons/opaa419. [DOI] [PubMed] [Google Scholar]
- 24.Zhong W., Chen Z., Zeng Y., et al. Two-level osteotomy for the corrective surgery of severe kyphosis from ankylosing spondylitis: a retrospective series. Spine (Phila Pa 1976) 2019;44:1638–1646. doi: 10.1097/BRS.0000000000003095. [DOI] [PubMed] [Google Scholar]
- 25.Debarge R., Demey G., Roussouly P. Radiological analysis of ankylosing spondylitis patients with severe kyphosis before and after pedicle subtraction osteotomy. Eur Spine J. 2010;19:65–70. doi: 10.1007/s00586-009-1158-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Auerbach J.D., Lenke L.G., Bridwell K.H., et al. Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 2012;37:1198–1210. doi: 10.1097/BRS.0b013e31824fffde. [DOI] [PubMed] [Google Scholar]
- 27.Baldus C.R., Bridwell K.H., Lenke L.G., Okubadejo G.O. Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls. Spine (Phila Pa 1976) 2010;35:235–239. doi: 10.1097/BRS.0b013e3181c86cb9. [DOI] [PubMed] [Google Scholar]
- 28.Kelly M.P., Lenke L.G., Shaffrey C.I., et al. Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study. Neurosurg Focus. 2014;36:E17. doi: 10.3171/2014.2.FOCUS1419. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.O'Lynnger T.M., Zuckerman S.L., Morone P.J., Dewan M.C., Vasquez-Castellanos R.A., Cheng J.S. Trends for spine surgery for the elderly: implications for access to Healthcare in north America. Neurosurgery. 2015;77(Suppl 4):S136–S141. doi: 10.1227/NEU.0000000000000945. [DOI] [PubMed] [Google Scholar]
- 30.Schwab F., Dubey A., Gamez L., et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976) 2005;30:1082–1085. doi: 10.1097/01.brs.0000160842.43482.cd. [DOI] [PubMed] [Google Scholar]
- 31.Lee M.J., Konodi M.A., Cizik A.M., Bransford R.J., Bellabarba C., Chapman J.R. Risk factors for medical complication after spine surgery: a multivariate analysis of 1,591 patients. Spine J. 2012;12:197–206. doi: 10.1016/j.spinee.2011.11.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Daubs M.D., Lenke L.G., Cheh G., Stobbs G., Bridwell K.H. Adult spinal deformity surgery: complications and outcomes in patients over age 60. Spine. 2007;32:2238. doi: 10.1097/BRS.0b013e31814cf24a. [DOI] [PubMed] [Google Scholar]
- 33.Qiao J., Xiao L., Sun X., et al. Vertebral subluxation during three-column osteotomy in surgical correction of adult spine deformity: incidence, risk factors, and complications. Eur Spine J. 2018;27:630–635. doi: 10.1007/s00586-017-5285-2. [DOI] [PubMed] [Google Scholar]
- 34.Eichler D., Charles Y.P., Baldairon F., Ntilikina Y., Sauleau E.A., Steib J.-P. Possible factors associated with sagittal malalignment recurrence after pedicle subtraction osteotomy. Eur Spine J. 2019;28:161–169. doi: 10.1007/s00586-018-5767-x. [DOI] [PubMed] [Google Scholar]
- 35.Zhao S.-Z., Qian B.-P., Huang J.-C., Qiao M., Wang B., Qiu Y. Failure patterns and related risk factors of sagittal reconstruction following pedicle subtraction osteotomy in patients with ankylosing spondylitis and thoracolumbar kyphosis. Neurosurg Focus. 2021;51:E7. doi: 10.3171/2021.7.FOCUS21146. [DOI] [PubMed] [Google Scholar]
- 36.Smith J.S., Shaffrey E., Klineberg E., et al. Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity: clinical article. J Neurosurg Spine. 2014;21:994–1003. doi: 10.3171/2014.9.SPINE131176. [DOI] [PubMed] [Google Scholar]
- 37.Phillips F.M., Carlson G., Emery S.E., Bohlman H.H. Anterior cervical pseudarthrosis. Natural history and treatment. Spine (Phila Pa 1976) 1997;22:1585–1589. doi: 10.1097/00007632-199707150-00012. [DOI] [PubMed] [Google Scholar]
- 38.Leven D., Cho S.K. Pseudarthrosis of the cervical spine: risk factors, diagnosis and management. Asian Spine J. 2016;10:776–786. doi: 10.4184/asj.2016.10.4.776. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Grubb S.A., Lipscomb H.J., Suh P.B. Results of surgical treatment of painful adult scoliosis. Spine. 1994;19:1619–1627. doi: 10.1097/00007632-199407001-00011. (Phila Pa 1976) [DOI] [PubMed] [Google Scholar]
- 40.Dinizo M., Srisanguan K., Dolgalev I., Errico T.J., Raman T. Pseudarthrosis and rod fracture rates after transforaminal lumbar interbody fusion at the caudal levels of long constructs for adult spinal deformity surgery. World Neurosurgery. 2021;155:e605–e611. doi: 10.1016/j.wneu.2021.08.099. [DOI] [PubMed] [Google Scholar]
- 41.How N.E., Street J.T., Dvorak M.F., et al. Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors. Neurosurg Rev. 2019;42:319–336. doi: 10.1007/s10143-018-0951-3. [DOI] [PubMed] [Google Scholar]
- 42.Martin C.T., Holton K.J., Elder B.D., et al. Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors. J Neurosurg Spine. 2022;38:98–106. doi: 10.3171/2022.6.SPINE211559. [DOI] [PubMed] [Google Scholar]
- 43.Bourghli A., Boissiere L., Obeid I. Dual iliac screws in spinopelvic fixation: a systematic review. Eur Spine J. 2019;28:2053–2059. doi: 10.1007/s00586-019-06065-3. [DOI] [PubMed] [Google Scholar]
- 44.Horsky J., Drucker E.A., Ramelson H.Z. Accuracy and completeness of clinical coding using ICD-10 for ambulatory visits. AMIA Annu Symp Proc. 2017;2017:912–920. [PMC free article] [PubMed] [Google Scholar]