PURPOSE: Surgical corrections for adult spinal deformity (ASD) often extend from T4-pelvis. Certain patients may require fusion from C2-pelvis. Comparisons are necessary to guide surgical decision-making, particularly for frailer patients with multiple comorbidities. This study analyzed the additional morbidity incurred by proceeding with fusion to the upper cervical spine (i.e., C2) versus to T4.
METHODS: This was a retrospective analysis comparing C2-pelvis versus T4-pelvis fusions for ASD. Patients were propensity-matched in a 1:4 ratio based on age, sex, ASA score, BMI, smoking, diabetes, and use of 3-column osteotomy. Outcomes included postoperative complications, hospital/ICU length-of-stay (LOS), time-to-ambulation, 30- and 90-day readmission rates, reoperations, and overall survival (OS).
RESULTS: 80 patients (16 C2-pelvis, 64 T4-pelvis) were analyzed. All patients had ASA scores ≥ 3. C2-pelvis yielded higher complication rates (100% C2-pelvis vs. 68.7% T4-pelvis; p = 0.008) and number of complications per patient (3.2 ± 2.2 C2-pelvis vs. 1.3 ± 1.6 T4-pelvis; p = 0.004). For specific complications, C2-pelvis more often yielded prolonged hypotension requiring vasopressors (p < 0.001), psychiatric complications (p = 0.04), and delirium (p = 0.04). Hospital LOS was similar between cohorts (p = 0.33), but ICU LOS (p = 0.02) and time-to-ambulation (p = 0.046) were longer after C2-pelvis. C2-pelvis had higher readmission rates within 30 (p = 0.001) and 90 (p = 0.001) days. OS was shorter after C2-pelvis (24.4 ± 2.8 months vs. 68.5 ± 4.2 months for T4-pelvis; p < 0.001).
CONCLUSIONS: C2-pelvis fusions for ASD yield significantly higher rates/numbers of complications, longer ICU LOS, longer time-to-ambulation, higher readmission rates, and shorter OS than T4-pelvis fusions, even among patients of similar age and systemic disease/comorbidities. Greater follow-up and numbers of C2-pelvis patients are required for more definitive outcome comparisons.
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