https://www.ipd.gu.se/digitalAssets/1252/1252566_Artikel_sept_Aina_Lancet_2_.pdf

Adolescent idiopathic scoliosis.

Study design Inter- and intra-rater variability study. Objective On the basis of a Scoliosis Research Society effort, this study seeks to determine whether the new adult spinal deformity (ASD) classification system is clear and reliable. Summary of background data A classification of adult ASD can serve several purposes, including consistent characterization of a clinical entity, a basis for comparing different treatments, and recommended treatments. Although pediatric scoliosis classifications are well established, an ASD classification is still being developed. A previous classification developed by Schwab et al has met with clinical relevance but did not include pelvic parameters, which have shown substantial correlation with health-related quality of life measures in recent studies. Methods Initiated by the Scoliosis Research Society Adult Deformity Committee, this study revised a previously published classification to include pelvic parameters. Modifier cutoffs were determined using health-related quality of life analysis from a multicenter database of adult deformity patients. Nine readers graded 21 premarked cases twice each, approximately 1 week apart. Inter- and intra-rater variability and agreement were determined for curve type and each modifier separately. Fleiss' kappa was used for reliability measures, with values of 0.00 to 0.20 considered slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1.00 almost perfect agreement. Results Inter-rater kappa for curve type was 0.80 and 0.87 for the 2 readings, respectively, with modifier kappas of 0.75 and 0.86, 0.97 and 0.98, and 0.96 and 0.96 for pelvic incidence minus lumbar lordosis (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA), respectively. By the second reading, curve type was identified by all readers consistently in 66.7%, PI-LL in 71.4%, PT in 95.2%, and SVA in 90.5% of cases. Intra-rater kappa averaged 0.94 for curve type, 0.88 for PI-LL, 0.97 for PT, and 0.97 for SVA across all readers. Conclusion Data from this study show that there is excellent inter- and intra-rater reliability and inter-rater agreement for curve type and each modifier. The high degree of reliability demonstrates that applying the classification system is easy and consistent.

Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study.

Study design Current concepts review. Objective Outline the basic principles in the evaluation and treatment of adult spinal deformity patients with a focus on goals to achieve during surgical realignment surgery. Summary of background data Proper global alignment of the spine is critical in maintaining standing posture and balance in an efficient and pain-free manner. Outcomes data demonstrate the clinical effect of spinopelvic malalignment and form a basis for realignment strategies. Methods Correlation between certain radiographic parameters and patient self-reported pain and disability has been established. Using normative values for several important spinopelvic parameters (including sagittal vertical axis, pelvic tilt, and lumbar lordosis), spinopelvic radiographic realignment objectives were identified as a tool for clinical application. Because of the complex relationship between the spine and the pelvis in maintaining posture and the wide range of "normal" values for the associated parameters, a focus on global alignment, with proportionality of individual parameters to each other, was pursued to provide clinical relevance to planning realignment for deformity across a range of clinical cases. Conclusion Good clinical outcome requires achieving proper spinopelvic alignment in the treatment of adult spinal deformity. Although variations in pelvic morphology exist, a framework has been established to determine ideal values for regional and global parameter in an individualized patient approach. When planning realignment surgery for adult spinal deformity, restoring low sagittal vertical axis and pelvic tilt values are critical goals, and should be combined with proportional lumbar lordosis to pelvic incidence.

Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery.

Background
There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥24 hours after injury) decompressive surgery after traumatic cervical SCI.

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Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).

Study design Prospective multicenter study evaluating operative (OP) versus nonoperative (NONOP) treatment for adult spinal deformity (ASD). Objective Evaluate correlations between spinopelvic parameters and health-related quality of life (HRQOL) scores in patients with ASD. Summary of background data Sagittal spinal deformity is commonly defined by an increased sagittal vertical axis (SVA); however, SVA alone may underestimate the severity of the deformity. Spinopelvic parameters provide a more complete assessment of the sagittal plane but only limited data are available that correlate spinopelvic parameters with disability. METHODS.: Baseline demographic, radiographical, and HRQOL data were obtained for all patients enrolled in a multicenter consecutive database. Inclusion criteria were: age more than 18 years and radiographical diagnosis of ASD. Radiographical evaluation was conducted on the frontal and lateral planes and HRQOL questionnaires (Oswestry Disability Index [ODI], Scoliosis Research Society-22r and Short Form [SF]-12) were completed. Radiographical parameters demonstrating highest correlation with HRQOL values were evaluated to determine thresholds predictive of ODI more than 40. Results Four hundred ninety-two consecutive patients with ASD (mean age, 51.9 yr) were enrolled. Patients from the OP group (n = 178) were older (55 vs. 50.1 yr, P Conclusion ASD is a disabling condition. Prospective analysis of consecutively enrolled patients with ASD demonstrated that PT and PI-LL combined with SVA can predict patient disability and provide a guide for patient assessment for appropriate therapeutic decision making. Threshold values for severe disability (ODI > 40) included: PT 22° or more, SVA 47 mm or more, and PI - LL 11° or more.

Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis.

Study Design. Combinations of metal implants (stainless steel (SS), titanium (Ti), and cobalt chrome (CC)) were placed in porcine spines. After 12 months, tissue response and implant corrosion were compared between mixed and single metal junctions. 
Objective. Model development and an attempt to determine any detriment of combining different metals in posterior spinal instrumentation. Methods. Yucatan mini-pigs underwent instrumentation over five unfused lumbar levels. A SS rod and a Ti rod were secured with Ti and SS pedicle screws, SS and Ti crosslinks, SS and CC sublaminar wires, and Ti sublaminar cable. The resulting 4 SS/SS, 3 Ti/Ti, and 11 connections between dissimilar metals per animal were studied after 12 months using radiographs, gross observation, and histology (foreign body reaction (FBR), metal particle count, and inflammation analyzed). Results. Two animals had constructs in place for 12 months with no complications. Histology of tissue over SS/SS connections demonstrated 11.1 ± 7.6 FBR cells, 2.1 ± 1.7 metal particles, and moderate to extensive inflammation. Ti/Ti tissue showed 6.3 ± 3.8 FBR cells, 5.2 ± 6.7 particles, and no to extensive inflammation (83% extensive). Tissue over mixed components had 14.1 ± 12.6 FBR cells and 13.4 ± 27.8 particles. Samples surrounding wires/cables versus other combinations demonstrated FBR (12.4 ± 13.5 versus 12.0 ± 9.6 cells, P = 0.96), particles (19.8 ± 32.6 versus 4.3 ± 12.7, P = 0.24), and inflammation (50% versus 75% extensive, P = 0.12). Conclusions. A nonfusion model was developed to study corrosion and analyze biological responses. Although no statistical differences were found in overlying tissue response to single versus mixed metal combinations, galvanic corrosion between differing metals is not ruled out. This pilot study supports further investigation to answer concerns when mixing metals in spinal constructs.

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The Biological Effects of Combining Metals in a Posterior Spinal Implant: In Vivo Model Development Report of the First Two Cases

Major Complications after Adult Spinal Deformity SurgeryIs There a High Risk Patient Profile?: 927

Management of spine deformity in young children presents one of the most challenging tasks in spine surgery. Idiopathic early onset scoliosis occurs in children before 10 years of age, and untreated deformity can result in significant morbidity. This chapter reviews the natural history of idiopathic early onset scoliosis, the clinical and radiographic evaluation of children with spinal deformity, and nonoperative and operative treatment options.

Idiopathic Early Onset Scoliosis

Comparison of primary and conversion surgery with magnetically controlled growing rods in children with early onset scoliosis (EOS)

Pediatric spinal deformity is an integral part of orthopaedic surgical practice. In a general or specialized practice, the well-versed orthopaedic surgeon should be aware of the diagnostic methods and the natural history from which practice standards are derived. It is important to be aware of the spectrum of spinal deformity in children (from early-onset scoliosis to adolescent idiopathic scoliosis, kyphosis, and spondylolisthesis) and current principles of growth and maturation as applied to the spine and the thorax. This information should be helpful in attaining the appropriate diagnosis, treatment, and/or referral for a pediatric patient with a spinal deformity.

Behrooz A. Akbarnia

Papers

The Biological Effects of Combining Metals in a Posterior Spinal Implant: In Vivo Model Development Report of the First Two Cases

Major Complications after Adult Spinal Deformity SurgeryIs There a High Risk Patient Profile?: 927

Idiopathic Early Onset Scoliosis

Comparison of primary and conversion surgery with magnetically controlled growing rods in children with early onset scoliosis (EOS)

Pediatric spinal deformity: what every orthopaedic surgeon needs to know.