Andrew Kai-Hong Chan, M.D.

Every field holds within its lofty ideals a pinnacle. If you are a serious mountaineer, the ultimate test of prowess likely lies in the ascent of Mount Everest or K2. For marathoners, it is the Boston Marathon. For professional football, it is the Super Bowl.Within the spine, spinal deformity reigns supreme as the most complex manifestation of spinal surgery. There are multiple reasons for this complexity including a practical limitation to the number of deformity cases trainees or practicing surgeons will be exposed to during their training and early career. Depending on one's training environment, there may not be a staff surgeon who regularly performs spinal deformity surgery. Likewise, depending on one's early practice environment, spinal deformity patients may not comprise a substantial number of clinic patients.

OBJECTIVE Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. METHODS Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire …

METHODS:This was a retrospective study of the prospective Quality Outcomes Database Cervical Spondylotic Myelopathy (QOD CSM) cohort. Social risk factors included race, education, employment, and insurance. Patients were considered to have improved from surgery if 1) they reported a score of 1 or 2 on the NASS index and 2) met the MCID in patient-reported outcomes (VAS neck and arm pain, NDI, EQ5D, or mJOA score) at 24-month follow-up.RESULTS:Of the 1,141 patients included in the study, 205 (18.0%) had zero, 347 (30.4%) had one, 334 (29.3%) had two, and 255 (22.3%) had three social risk factors. The 24-month follow-up rate was 87.4% for patient-reported outcomes. After adjusting for all significant covariates, patients with one or more social risk factors were less likely to improve from surgery in all measured outcomes including VAS neck and arm pain, NDI, EQ-5D, and mJOA (all p< 0.05 …

Purpose: Spinal fusion incurs risk of surgical site infection and wound dehiscence. Concomitant muscle flap closure may mitigate these risks. While benefits of muscle flap closure have been established, sociodemographic and hospital-level influences on access to this procedure remain unexplored.Methods: Patients who received spinal fusions of two or more vertebral levels (n= 130,666) were identified via ICD-10-PCS codes from the 2016-2018 National Inpatient Sample databases. The primary outcome was reception of muscle flap closure. 1: 1 propensity score matching was conducted on age and comorbidity score as indicators of case severity, and number of spinal levels fused (fewer than or more than eight levels) and length of stay as indicators of surgical complexity. Binary multivariate logistic regression identified sociodemographic and hospital-level predictors of receiving muscle flap closure.Results: 803 …

METHODS:This was an analysis of the prospective Quality Outcomes Database Cervical Spondylotic Myelopathy (QOD CSM) cohort which included adult patients who were diagnosed with primary CSM undergoing elective surgery. Patient-reported outcomes including VAS neck and arm pain, NDI, mJOA, EQ-5D, and NASS patient satisfaction were collected at baseline and 24 months.RESULTS:Of the 239 patients with CSM who underwent PCF, 48 (20.1%) had UIV of C2 and 191 (79.9%) had UIV of C3/below. The 24-month follow-up rate was 87.4% for patient-reported outcomes. At baseline, C2 group had a higher frequency of motor deficit (83.3% vs 68.1%, p= 0.04) compared to the C3/below group; otherwise, there was no difference in pain, function, and quality of life. C2 group had greater number of treated levels (6.1±2.0 vs 4.5±1.3, p< 0.01) compared to the C3/below group. At 24-month follow-up, the two …

OBJECTIVE Cervical spondylotic myelopathy (CSM) can cause significant difficulty with driving and a subsequent reduction in an individual’s quality of life due to neurological deterioration. The positive impact of surgery on postoperative patient-reported driving capabilities has been seldom explored. METHODS The CSM module of the Quality Outcomes Database was utilized. Patient-reported driving ability was assessed via the driving section of the Neck Disability Index (NDI) questionnaire. This is an ordinal scale in which 0 represents the absence of symptoms while driving and 5 represents a complete inability to drive due to symptoms. Patients were considered to have an impairment in their driving ability if they reported an NDI driving score of 3 or higher (signifying impairment in driving duration due to symptoms). Multivariable logistic regression models were fitted to …

The population of older adults is rapidly growing. In-home monitoring systems have been used to support aging-in-place. Ambient sensors or wearable localizers can be used but may be too low resolution, while camera systems are invasive to privacy. Ultra-wideband (UWB) localization offers precise positioning by placing anchors throughout the house and wearing a tag that is tracked by the anchors. In this study, the accuracy of UWB for indoor tracking was evaluated in a motion capture gait lab and in a mock condo in the Glenrose Rehabilitation Hospital. First, the configuration of UWB was tested, changing factors related to sampling time, anchor placement and line-of-sight. Comparing these factors to the configurations recommended by the manufacturer guidelines, accuracies remained within 14 cm. We then performed static and dynamic accuracy tests, with dynamic testing comprised of rolling and walking …

METHODS:This was an analysis of the prospective Quality Outcomes Database CSM module. Patients of age= 18 years diagnosed with primary CSM who underwent elective surgery were included. PROs (VAS neck and arm pain, NDI, mJOA, EQ-5D, and NASS patient satisfaction) were collected at baseline and 24 months.RESULTS:Of the 1,141 patients with CSM, 202 (17.7%) were smokers and 939 (82.3%) were non-smokers. Compared to the non-smokers, smokers were younger (56.3±11.3 vs 61.5±11.7, p< 0.01) and had lower BMI (29.3±6.8 vs 30.3±6.3, p= 0.04). A higher number of smokers had depression, anxiety, and COPD (all p< 0.01). At baseline, smokers had worse pain (neck: 6.0±3.2 vs 5.1±3.3; arm: 5.7±3.2 vs 4.7±3.5), disability (NDI: 45.2±20.0 vs 37.1±20.6), myelopathy (mJOA: 11.5±2.9 vs 12.2±2.8), and quality of life (EQ-5D: 0.51±0.23 vs 0.57±0.22)(all p< 0.01). At 24-month follow-up, a higher …

Our aim is to review the most recent evidence on novel antibody therapies for Alzheimer's disease directed against amyloid‐β. This is a joint statement of the European Association of Neurology and the European Psychiatric Association. After numerous unsuccessful endeavors to create a disease‐modifying therapy for Alzheimer's disease, substantial and consistent evidence supporting the clinical effectiveness of monoclonal antibodies aimed at amyloid‐β is finally emerging. The latest trials not only achieved their primary objective of slowing the progression of the disease over several months but also demonstrated positive secondary clinical outcomes and a decrease in amyloid‐β levels as observed through positron emission tomography scans. Taken as a whole, these findings mark a significant breakthrough by substantiating that reducing amyloid‐β yields tangible clinical benefits, beyond mere changes in …

OBJECTIVE The objective of this study was to compare clinical and patient-reported outcomes (PROs) between posterior foraminotomy and anterior cervical discectomy and fusion (ACDF) in patients presenting with cervical radiculopathy. METHODS The Quality Outcomes Database was queried for patients who had undergone ACDF or posterior foraminotomy for radiculopathy. To create two highly homogeneous groups, optimal individual matching was performed at a 5:1 ratio between the two groups on 29 baseline variables (including demographic characteristics, comorbidities, symptoms, patient-reported scores, underlying pathologies, and levels treated). Outcomes of interest were length of stay, reoperations, patient-reported satisfaction, increase in EQ-5D score, and decrease in Neck Disability Index (NDI) scores for arm and neck pain as long as 1 year after surgery …

OBJECTIVE It is not clear whether there is an additive effect of social factors in keeping patients with cervical spondylotic myelopathy (CSM) from achieving both a minimum clinically important difference (MCID) in outcomes and satisfaction after surgery. The aim of this study was to explore the effect of multiple social factors on postoperative outcomes and satisfaction. METHODS This was a multiinstitutional, retrospective study of the prospective Quality Outcomes Database (QOD) CSM cohort, which included patients aged 18 years or older who were diagnosed with primary CSM and underwent operative management. Social factors included race (White vs non-White), education (high school or below vs above), employment (employed vs not), and insurance (private vs nonprivate). Patients were considered to have improved from surgery if the following criteria were met: 1 …

METHODS:This is a retrospective analysis of the multicenter, prospectively collected Quality Outcomes Database (QOD). Patients with surgically treated grade I lumbar spondylolisthesis with five years of follow-up were included. Patient reported outcomes (PROs) were recorded. Patients were grouped into baseline dependent or independent cohorts based on the Personal Care component of the ODI (0-2= independent; ³3= dependent). Minimum clinically important difference (MCID) was defined as a 30% reduction from baseline disability.RESULTS:Of the 602 patients, 535 (89%) were independent and 67 (11%) were dependent at baseline with mean age of 63 and 59, respectively (p= 0.01). 479 patients (80%) reported 60-month follow up Personal Care scores, with 59% reporting improvement and 41% having worse or no improvement. At 60-month follow-up, 87.5% of dependent patients had gained lasting …

METHODS:The CSM database of the QOD Study Group was utilized for this analysis. Patients were prospectively enrolled and followed for 24 months, with a follow-up rate of 85.2%. The MCIDs were computed for five standardized instruments: Neck Disability Index (NDI), five-dimension Euro-QoL (EQ-5D) in QALYs, neck and arm pain numeric rating scale (NRS), and modified Japanese Orthopedic Association score (mJOA) at both 3 and 24-month follow-up. Seven previously validated measures of MCID were compared using the area-under-the-curve (AUC). The North American Spine Society (NASS) satisfaction scale was the anchor, with scores of 1-2 meeting criteria for satisfaction.RESULTS:A total of 1,141 patients underwent surgery for CSM. Improvement of= 30% from baseline was the optimal MCID across time points for NDI and neck/arm NRS. At 24 months, 30% improvement for these three instruments …

Study Design.External validation using prospectively collected data.Objectives.To determine the model performance of “Dialogue Support”(DS) in predicting outcomes after lumbar spine surgery.Summary of Background Data.To help clinicians discuss risk versus benefit with patients considering lumbar fusion surgery, DS has been made available online. As DS was created using a Swedish sample, there is a need to study how well DS performs in alternative populations.Patients and Methods.Preoperative data from patients enrolled in the Quality Outcomes Database were entered into DS. The probability for each patient to report satisfaction, achieve success (leg pain improvement≥ 3), or have no leg pain 12 months after surgery was extracted and compared with their actual 12-month postoperative data. The ability of DS to identify patients in the Quality Outcomes Database who report satisfaction, achieve …

Study Design:Retrospective review of a prospectively maintained database.Objective:Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM).Summary of Background Data:Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care.Methods:The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms> 3 or≤ 3 months, and 24-month patient-reported outcome measures were evaluated.Results:Among 1141 patients with …

METHODS:The prospective QOD CSM cohort was queried for fusions across only three interspaces. Surgeries crossing the cervicothoracic junction were excluded. The cohort was divided into anterior cervical discectomy and fusion (ACDF) and posterior laminectomy-and-fusion. 24-month patient-reported outcomes were compared.RESULTS:Of 199 patients (123 ACDF, 76 posterior fusions), 24-month follow-up rates were similar (ACDF: 90.2% vs. 92.1%, p= 0.67). Preoperatively, ACDF were younger (60.8±10.2 vs. 65.0±10.3 yr, p< 0.01), used more private insurance (56.1% vs. 36.8%, p= 0.02), were more often employed (39.8% vs. 22.8%, p= 0.04), and independently ambulatory (14.6% vs. 31.6%, p< 0.01). Otherwise, the cohorts had equivalent baseline mJOA, NDI, NRS Arm-Pain, NRS Neck-Pain, and EQ-5D (p> 0.05). ACDF had shorter hospitalizations (1.6 vs. 3.9 days, p< 0.01) and less non-routine discharge …

OBJECTIVE The aim of this study was to identify predictors of the best 24-month improvements in patients undergoing surgery for cervical spondylotic myelopathy (CSM). For this purpose, the authors leveraged a large prospective cohort of surgically treated patients with CSM to identify factors predicting the best outcomes for disability, quality of life, and functional status following surgery. METHODS This was a retrospective analysis of prospectively collected data. The Quality Outcomes Database (QOD) CSM dataset (1141 patients) at 14 top enrolling sites was used. Baseline and surgical characteristics were compared for those reporting the top and bottom 20th percentile 24-month Neck Disability Index (NDI), EuroQol-5D (EQ-5D), and modified Japanese Orthopaedic Association (mJOA) change scores. A multivariable logistic model was constructed and included candidate …

Restoration of physiologic lumbar lordosis is a key principle in adult spinal deformity surgery and an essential strategy in the restoration of sagittal alignment. Extensive literature has established that the restoration of lordosis to within 10 of pelvic incidence is associated with improved postoperative outcomes including lower rates of disability, increased quality of life, and lower incidence of proximal junctional kyphosis. 1–4 More recent studies have focused on the potential need for age-matched pelvic incidence-lumbar lordosis mismatch goals affording less aggressive correction targets in older patients. 5 Likewise, the development of the global alignment and proportion score has sought to capture nuanced impacts of the full pelvic incidence spectrum as well as the distribution of lordosis on overall alignment and surgical success. 6 Relatedly, there is increasing evidence that, throughout the population, proximal …

Introduction In a multilevel cervical laminoplasty operation for patients with cervical spondylotic myelopathy (CSM), a partial or complete C3 laminectomy may be performed at the upper level instead of a C3 plated laminoplasty. It is unknown whether C3 technique above the laminoplasty affects loss of cervical lordosis or range of motion. Methods Patients undergoing multilevel laminoplasty of the cervical spine (C3–C6/C7) at a single institution were retrospectively reviewed. Patients were divided into two cohorts based on surgical technique at C3: C3–C6/C7 plated laminoplasty (“C3 laminoplasty only”, N = 61), C3 partial or complete laminectomy, plus C4–C6/C7 plated laminoplasty (N = 39). All patients had at least 1-year postoperative X-ray treatment. Results Of 100 total patients, C3 laminoplasty and C3 laminectomy were equivalent in all demographic data, except for age (66.4 vs. 59.4 years, p = 0.012). None of the preoperative radiographic parameters differed between the C3 laminoplasty and C3 laminectomy cohorts: cervical lordosis (13.1° vs. 11.1°, p = 0.259), T1 slope (32.9° vs. 29.2°, p = 0.072), T1 slope–cervical lordosis (19.8° vs. 18.6°, p = 0.485), or cervical sagittal vertical axis (3.1 cm vs. 2.7 cm, p = 0.193). None of the postoperative radiographic parameters differed between the C3 laminoplasty and C3 laminectomy cohorts: cervical lordosis (9.4° vs. 11.2°, p = 0.369), T1 slope–cervical lordosis (21.7° vs. 18.1°, p = 0.126), to cervical sagittal vertical axis (3.3 cm vs. 3.6 cm, p = 0.479). In the total cohort, 31% had loss of cervical lordosis >5°. Loss of lordosis reached 5–10° (mild change) in 13% of patients and >10° (moderate change) in …

OBJECTIVE The aim of this study was to explore the preoperative patient characteristics that affect surgical decision-making when selecting an anterior or posterior operative approach in patients diagnosed with cervical spondylotic myelopathy (CSM). METHODS This was a multi-institutional, retrospective study of the prospective Quality Outcomes Database (QOD) Cervical Spondylotic Myelopathy module. Patients aged 18 years or older diagnosed with primary CSM who underwent multilevel (≥ 2-level) elective surgery were included. Demographics and baseline clinical characteristics were collected. RESULTS Of the 841 patients with CSM in the database, 492 (58.5%) underwent multilevel anterior surgery and 349 (41.5%) underwent multilevel posterior surgery. Surgeons more often performed a posterior surgical approach in older patients (mean …