title: Lower Risk of Stroke after Deformity Surgery: Long Term Benefit Demonstrated by a National Cohort Study.
abstract: OBJECTIVE
  This study aimed to investigate the long-term risk of stroke in adult patients with spinal deformity. Specifically, the study addressed the possible protective effect of surgery for spinal deformity against stroke.
  
  
  METHODS
  Using the National Health Insurance Research Database (NHIRD), a monopolistic national database in Taiwan, this retrospective cohort study analyzed the incidence of stroke in patients with adult spinal deformity (ASD) in a 11-year period. A total of 13,503 patients, between 55 and 75 years old, were identified for the diagnosis of ASD. The patients were grouped into two: the surgical group (n = 10,439) who received spinal fusion surgery, and the control group (n = 2124) who received other medical treatment. The incidence rates of all subsequent cerebrovascular accidents, including ischemic and hemorrhagic strokes, were calculated. Hazard ratios for stroke were calculated use a full cohort and a propensity score matched cohort. Adjustments for co-morbidities that may predispose to stroke, including hypertension, diabetes mellitus, arrhythmia and coronary heart disease were conducted. Kaplan-Meier and Cox regression analyses were performed to compare the risk of stroke between the two groups.
  
  
  RESULTS
  During the total observation period of 50,450 person-years, the incidence rate of stroke in the surgical group (15.55 per 1000 person-years) was significantly lower than that of the control group (20.89 per 1000 person-years, p < 0.001). Stroke was more likely to occur in the control group than in the surgical group (crude hazard ratio 1.34, p < 0.001; adjusted HR 1.28, p < 0.001, by a propensity score matched model).
  
  
  CONCLUSIONS
  In this national cohort of more than 13,000 ASD patients covering 10 years, stroke was approximately 25% less likely to happen in patients who underwent spinal fusion surgery than those who received medical management. Therefore, spinal fusion surgery may provide a protective effect against stroke in adult patients with spinal deformity.
authors.affiliation: Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan 260, Taiwan. horus7855@yahoo.com.tw.
authors.forename: Liang-Chung
authors.initials: LC
authors.lastname: Huang
authors.affiliation: Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan 260, Taiwan. wolfchung2001@yahoo.com.tw.
authors.forename: Wu-Fu
authors.initials: WF
authors.lastname: Chung
authors.affiliation: Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan 260, Taiwan. shihweiliu123@gmail.com.
authors.forename: Shih-Wei
authors.initials: SW
authors.lastname: Liu
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. acidbummer@gmail.com.|Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Beitou, Taipei 11217, Taiwan. acidbummer@gmail.com.
authors.forename: Peng-Yuan
authors.initials: PY
authors.lastname: Chang
authors.affiliation: Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan 260, Taiwan. 12206@ymuh.ym.edu.tw.|School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. 12206@ymuh.ym.edu.tw.
authors.forename: Li-Fu
authors.initials: LF
authors.lastname: Chen
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. jauching@gmail.com.|Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Beitou, Taipei 11217, Taiwan. jauching@gmail.com.
authors.forename: Jau-Ching
authors.initials: JC
authors.lastname: Wu
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. yuchn.chen@gmail.com.|Department of Medical Research and Education, National Yang-Ming University Hospital, I-Lan 260, Taiwan. yuchn.chen@gmail.com.|Institute of Hospital and Health Care Administration, School of Medicine, National Yang-Ming University, Taipei 260, Taiwan. yuchn.chen@gmail.com.
authors.forename: Yu-Chun
authors.initials: YC
authors.lastname: Chen
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. wchuang@vghtpe.gov.tw.|Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Beitou, Taipei 11217, Taiwan. wchuang@vghtpe.gov.tw.
authors.forename: Wen-Cheng
authors.initials: WC
authors.lastname: Huang
authors.affiliation: Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan. lauraliu@cgmh.org.tw.|College of Medicine, Chang Gung University, Taoyuan 333, Taiwan. lauraliu@cgmh.org.tw.
authors.forename: Laura
authors.initials: L
authors.lastname: Liu
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. hc_cheng@vghtpe.gov.tw.|Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Beitou, Taipei 11217, Taiwan. hc_cheng@vghtpe.gov.tw.|Institute of Pharmacology, National Yang-Ming University, Taipei 112, Taiwan. hc_cheng@vghtpe.gov.tw.
authors.forename: Henrich
authors.initials: H
authors.lastname: Cheng
authors.affiliation: School of Medicine, National Yang-Ming University, Taipei 112, Taiwan. sslo@ymuh.ym.edu.tw.
authors.forename: Su-Shun
authors.initials: SS
authors.lastname: Lo
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012044:Regression Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D013131:Spine / Q000002:abnormalities / Q000601:surgery*; D020521:Stroke / Q000453:epidemiology* / Q000209:etiology; D013624:Taiwan / Q000453:epidemiology; D019616:Thoracic Surgical Procedures
keywords: adult spinal deformity (ASD), spinal fusion surgery, stroke, National Health Insurance Research Database (NHIRD)