714270 - Defining an Algorithm for Treatment of Severe Cervical Deformity Using Surgeon Survey and Treatment Patterns

Thursday, February 27, 2020

1:50 PM – 1:55 PM

Location: Ballroom B

Participants should be aware of the following financial/non-financial relationships:

Sohrab Virk, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Jonathan Elysee, BS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Munish C. Gupta, MD: Alphatec (Individual(s) Involved: Self, Products/Services: consultant): consultant, travel; AO Spine (Individual(s) Involved: Self, Products/Services: speaker): honorarium; Depuy Spine (Individual(s) Involved: Self, Products/Services: consultant): Royalty, consultant, advisory, travel; Globus (Individual(s) Involved: Self, Products/Services: travel): travel; Innomed (Individual(s) Involved: Self, Products/Services: instruments): royalty; Johnson & Johnson (Individual(s) Involved: Self, Products/Services: stock): stock; Medtronic (Individual(s) Involved: Self, Products/Services: consultant): consultant, advisory, travel; Proctor & Gamble (Individual(s) Involved: Self, Products/Services: stock): stock; Scoliosis Research Society (Individual(s) Involved: Self, Products/Services: faculty): travel as faculty

Eric Klineberg, MD: AOSpine (Individual(s) Involved: Self, Products/Services: Honoraria and Fellowship Grant): ; Depuy Synthes (Individual(s) Involved: Self, Products/Services: Consulting): ; Medicrea (Individual(s) Involved: Self, Products/Services: Consulting): ; Stryker (Individual(s) Involved: Self, Products/Services: Consulting):

Frank Schwab, MD: Globus Medical (Individual(s) Involved: Self, Products/Services: product design): consulting; International Spine Study Group (Individual(s) Involved: Self, Products/Services: n/a): advisory board; K2 Medical, LLC (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Medicrea (Individual(s) Involved: Self, Products/Services: n/a): Royalties; Medtronic (Individual(s) Involved: Self, Products/Services: Royalties): Royalties

Han Jo Kim, MD: BIOMET (Now ZIMMER BIOMET) (Individual(s) Involved: Self, Products/Services: Inventor): Royalty; K2M Stryker Spine (Individual(s) Involved: Self, Products/Services: Inventor): Royalty

Douglas Burton, MD: Bioventus (Individual(s) Involved: Self, Products/Services: Consultant): Consultant; Depuy Spine (Individual(s) Involved: Self, Products/Services: Research support, consultant, royalties): ; Pfizer (Individual(s) Involved: Self, Products/Services: Research support): Research support; Progenerative Medical (Individual(s) Involved: Self, Products/Services: Stock): Consultant.

Peter G. Passias, MD: AlloSource (Individual(s) Involved: Self, Products/Services: Financial Support): Financial Support; Globus Medical (Individual(s) Involved: Self, Products/Services: Paid Presenter or Speaker): Paid Presenter or Speaker; Medicrea (Individual(s) Involved: Self, Products/Services: N/a): Paid consultant; SpineWave (Individual(s) Involved: Self, Products/Services: Paid Consultant): Paid consultant; The Cervical Spine Research Society (Individual(s) Involved: Self, Products/Services: Grant): Grant; Zimmer Biomet (Individual(s) Involved: Self, Products/Services: Paid Presenter or Speaker): Paid Presenter or Speaker

Themistocles S. Protopsaltis, MD: Altus Spine (Individual(s) Involved: Self, Products/Services: N/A): Royalties; Globus Medical (Individual(s) Involved: Self, Products/Services: N/A): Consulting; Innovasis (Individual(s) Involved: Self, Products/Services: N/A): Consulting; Medicrea (Individual(s) Involved: Self, Products/Services: N/A): Consulting; NuVasive (Individual(s) Involved: Self, Products/Services: N/A): Consulting, Consulting; Stryker/K2M (Individual(s) Involved: Self, Products/Services: N/A): Consulting

Justin S. Smith, MD: AlloSource (Individual(s) Involved: Self, Products/Services: none): consultant; Alphatec (Individual(s) Involved: Self, Products/Services: stock owner): stock owner; AOSpine (Individual(s) Involved: Self, Products/Services: fellowship support): fellowship support; Cerapedics (Individual(s) Involved: Self, Products/Services: none): consultant; Depuy Synthes (Individual(s) Involved: Self, Products/Services: Research study group support): Research study group support; NREF (Individual(s) Involved: Self, Products/Services: fellowship support): fellowship support; NuVasive (Individual(s) Involved: Self, Products/Services: implants): consultant, royalties; Stryker/K2M (Individual(s) Involved: Self, Products/Services: BACS): consultant; Zimmer Biomet (Individual(s) Involved: Self, Products/Services: Instrumentation): consultant, royalties

Christopher P. Ames, MD: BIOMET (Now ZIMMER BIOMET) (Individual(s) Involved: Self, Products/Services: Consulting): Consulting; BIOMET (Now ZIMMER BIOMET) (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Depuy Synthes (Individual(s) Involved: Self, Products/Services: Consulting): Consulting; Depuy Synthes (Individual(s) Involved: Self, Products/Services: Research): Research; Depuy Synthes (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Global Spine Analytics (Individual(s) Involved: Self, Products/Services: Director): Director; International Spine Study Group (Individual(s) Involved: Self, Products/Services: Executive Committee): Executive Committee; International Spine Study Group (Individual(s) Involved: Self, Products/Services: Research): Research; K2M (Individual(s) Involved: Self, Products/Services: Consulting): Consulting; K2M (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Medicrea (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Medtronic (Individual(s) Involved: Self, Products/Services: Consulting): Consulting; Next Orthosurgical (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; NuVasive (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Operative Neurosurgery (Individual(s) Involved: Self, Products/Services: Editorial Board): Editorial Board; Scoliosis Research Society (SRS) (Individual(s) Involved: Self, Products/Services: Grant Funding): Grant Funding; Stryker (Individual(s) Involved: Self, Products/Services: Consulting): Consulting; Stryker (Individual(s) Involved: Self, Products/Services: Royalties): Royalties; Titan Spine (Individual(s) Involved: Self, Products/Services: Research): Research

Renaud Lafage, MS: Nemaris (Individual(s) Involved: Self, Products/Services: Ownership interest):

Virginie Lafage, PhD: Depuy Spine (Individual(s) Involved: Self, Products/Services: n/a): Speaking/teaching arrangements; Globus Medical (Individual(s) Involved: Self, Products/Services: n/a): consulting; International Spine Study Group (Individual(s) Involved: Self, Products/Services: n/a): advisory board; NuVasive (Individual(s) Involved: Self, Products/Services: n/a): consulting

International Spine Study Group: AlloSource (Individual(s) Involved: Self, Products/Services: na): Research; Depuy Synthes (Individual(s) Involved: Self, Products/Services: na): Research; Globus Medical, Inc. (Individual(s) Involved: Self, Products/Services: na): Research; Medtronic Inc. (Individual(s) Involved: Self, Products/Services: na): Research; NuVasive, Inc (Individual(s) Involved: Self, Products/Services: na): Research; Orthofix (Individual(s) Involved: Self, Products/Services: na): Research; SI Bone (Individual(s) Involved: Self, Products/Services: na): Research; Stryker/K2M (Individual(s) Involved: Self, Products/Services: na): Research

Background: Patients with severe cervical deformity (sCD) present a unique challenge to surgeons. The literature currently provides only limited guidance on operative strategies for this difficult patient population.

Purpose: To create an algorithm for selection of approach, upper-most instrumented vertebrae (UIV), lower-most instrumented vertebrae (LIV), and performing a VCR/PSO for patients with sCD.
Study Design/Setting: Survey of surgeons and retrospective review of prospective CD database.
Eligible population: Adult sCD patients (C2-C7 Cobb>10°, CL>10°, cSVA>4cm, or CBVA>25°).
Length of follow-up: N/A
Patient accountability: N/A
Outcome Measures: Operative treatment for sCD

Methods: Surgical patients with sCD were isolated based upon a previously presented combination of preop cSVA, T1 slope, max focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. We sent 10 sCD cases with a clinical vignette, radiographic and advanced imaging to identify consensus reasoning for 1) approach 2) UIV 3) LIV and 4) performance VCR/PSO among 7 deformity surgeons. Agreement was defined as 5 or more surgeons agreeing on any 4 questions listed. We performed a descriptive analysis of responses and created an algorithm for each of the 4 questions posed. We retrospectively applied the algorithm to a database of patients with sCD and determined whether the operative treatment followed our algorithm.

Results: There was consensus on 5/10 cases for posterior approach because of CT deformity or a high cSVA. Of 15 pts with cSVA>5cm and T1S>50° we found 13/15 had a posterior approach and 2/15 had an antero-posterior (AP) approach. Two cases had consensus of AP, because of local kyphosis. Of 25 pts with a local kyphosis >18°, 14 had an AP, 7 had posterior and 4 had anterior. There was a higher rate of osteotomies for posterior versus AP approach (6/7 vs 3/14). UIV was consensus for C2 for 5/10 cases, because of fusion length and fixation strength. Of 35 pts that had a posterior fusion >6 levels, 20/35 had a UIV of C2. 3/10 cases had consensus LIV below a UIV of previous fusion. If a previous UIV was at T6 or higher then 34/36 pts had a LIV below previous UIV. In 6/10 cases a VCR/PSO was not needed due to flexibility of the cervical spine. Of 12 pts within the database that had a VCR/PSO there were 9/12 that had >10° of change in C2-C7 Cobb angle on flex/ex radiographs.

Conclusion: Using consensus agreement among deformity surgeons we would recommend for sCD patients that 1) if T1 slope > 50 deg and cSVA > 5cm then a posterior approach be considered, 2) if local kyphosis is >18 deg then an anterior-posterior approach be considered 3) if there is instrumentation higher than T6 then the LIV bypass old instrumentation and 4) if there is greater than 10 degrees in C2-C7 cobb angle motion on flex/ex radiographs a VCR/PSO may not be necessary.

Presenting Author(s)

Sohrab Virk, MD

Fellow
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

Jonathan Elysee, BS

Research Engineer
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Munish C. Gupta, MD

Mildred B. Simon Distinguished Professor of Orthopaedic Surgery, Professor of Neurological Surgery
Department of Orthopaedic Surgery, Washington University

Disclosure: Alphatec : consultant, travel (Status: Terminated --- 2019); AO Spine : honorarium (Status: Ongoing); Depuy Spine : Royalty, consultant, advisory, travel (Status: Ongoing); Globus : travel (Status: Terminated --- ); Innomed : royalty (Status: Ongoing); Johnson & Johnson : stock (Status: Ongoing); Medtronic : consultant, advisory, travel (Status: Ongoing); Proctor & Gamble : stock (Status: Ongoing); Scoliosis Research Society : travel as faculty (Status: Ongoing)
Eric Klineberg, MD

Professor, Vice Chair Department of Orthopaedic Surgery
University of California, Davis

Disclosure: AOSpine (Individual(s) Involved: Self, Products/Services: Honoraria and Fellowship Grant): ; Depuy Synthes (Individual(s) Involved: Self, Products/Services: Consulting): ; Medicrea (Individual(s) Involved: Self, Products/Services: Consulting): ; Stryker (Individual(s) Involved: Self, Products/Services: Consulting):
Frank Schwab, MD

attending surgeon
Hospital for Special Surgery

Disclosure: Globus Medical : consulting (Status: Ongoing); International Spine Study Group : advisory board (Status: Ongoing); K2 Medical, LLC : Royalties (Status: Ongoing); Medicrea : Royalties (Status: Ongoing); Medtronic : Royalties (Status: Ongoing)
Han Jo Kim, MD

Fellowship Director
Hospital for Special Surgery

Disclosure: BIOMET (Now ZIMMER BIOMET) : Royalty (Status: Ongoing); K2M Stryker Spine : Royalty (Status: Ongoing)
Douglas Burton, MD

Professor of Orthopedic Surgery
Kansas University Medical Center

Disclosure: Bioventus : Consultant (Status: Terminated --- 2019); Pfizer : Research support (Status: Terminated --- 2019); Progenerative Medical : Consultant. (Status: Ongoing)
Peter G. Passias, MD

Associate Professor NYU School of Medicine
NYU Langone Orthopedic Hospital

Disclosure: AlloSource : Financial Support (Status: Ongoing); Globus Medical : Paid Presenter or Speaker (Status: Ongoing); Medicrea : Paid consultant (Status: Ongoing); SpineWave : Paid consultant (Status: Ongoing); The Cervical Spine Research Society : Grant (Status: Ongoing); Zimmer Biomet : Paid Presenter or Speaker (Status: Ongoing)
Themistocles S. Protopsaltis, MD

Chief, Division of Spine Surgery, Department of Orthopaedic Surgery
New York University Langone Orthopedic Hospital

Disclosure: Altus Spine : Royalties (Status: Ongoing); Globus Medical : Consulting (Status: Ongoing); Innovasis : Consulting (Status: Ongoing); Medicrea : Consulting (Status: Ongoing); NuVasive : Consulting (Status: Ongoing), Consulting (Status: Ongoing); Stryker/K2M : Consulting (Status: Ongoing)
Justin S. Smith, MD

Harrison Distinguished Professor of Neurosurgery
University of Virginia Health System : Spine Center

Disclosure: AlloSource : consultant (Status: Ongoing); Alphatec : stock owner (Status: Ongoing); AOSpine : fellowship support (Status: Ongoing); Cerapedics : consultant (Status: Ongoing); Depuy Synthes : Research study group support (Status: Ongoing); NREF : fellowship support (Status: Ongoing); NuVasive : consultant, royalties (Status: Ongoing); Stryker/K2M : consultant (Status: Ongoing); Zimmer Biomet : consultant, royalties (Status: Ongoing)
Christopher P. Ames, MD

Professor of Clinical Neurological Surgery and Orthopaedic Surgery
UCSF

Disclosure: BIOMET (Now ZIMMER BIOMET) : Consulting (Status: Ongoing), Royalties (Status: Ongoing); Depuy Synthes : Consulting (Status: Ongoing), Research (Status: Ongoing), Royalties (Status: Ongoing); Global Spine Analytics : Director (Status: Ongoing); International Spine Study Group : Executive Committee (Status: Ongoing), Research (Status: Ongoing); K2M : Consulting (Status: Ongoing), Royalties (Status: Ongoing); Medicrea : Royalties (Status: Ongoing); Medtronic : Consulting (Status: Ongoing); Next Orthosurgical : Royalties (Status: Ongoing); NuVasive : Royalties (Status: Ongoing); Operative Neurosurgery : Editorial Board (Status: Ongoing); Scoliosis Research Society (SRS) : Grant Funding (Status: Ongoing); Stryker : Consulting (Status: Ongoing), Royalties (Status: Ongoing); Titan Spine : Research (Status: Ongoing)
Renaud Lafage, MS

Scientist
Hospital For Special Surgery

Disclosure: Nemaris (Individual(s) Involved: Self, Products/Services: Ownership interest):
Virginie Lafage, PhD

Senior Director Spine Research
Hospital for Special Surgery
Hospital for Special Surgery

Disclosure: Depuy Spine : Speaking/teaching arrangements (Status: Ongoing); Globus Medical : consulting (Status: Ongoing); International Spine Study Group : advisory board (Status: Ongoing); NuVasive : consulting (Status: Ongoing)
International Spine Study Group

na
ISSGF

Disclosure: AlloSource : Research (Status: Ongoing); Depuy Synthes : Research (Status: Ongoing); Globus Medical, Inc. : Research (Status: Ongoing); Medtronic Inc. : Research (Status: Ongoing); NuVasive, Inc : Research (Status: Ongoing); Orthofix : Research (Status: Ongoing); SI Bone : Research (Status: Ongoing); Stryker/K2M : Research (Status: Ongoing)