STUDY DESIGN: Retrospective case series of surgically treated adult scoliosis patients. OBJECTIVE: To assess the incidence, risk factors and clinical outcomes of proximal junctional kyphosis (PJK) in a large series of adult idiopathic scoliosis patients undergoing long instrumented spinal fusion (.5 vertebrae). A new classification is also projected. SUMMARY OF BACKGROUND DATA: Maintaining both coronal and sagittal balance is essential in the surgical treatment of adult deformity patients. PJK is a well-recognized postoperative phenomenon in adults and adolescents after scoliosis surgery. Despite recent reports, the prevalence, clinical outcomes, and the risk factors of PJK are still controversial. MATERIALS AND METHODS: This study is a retrospective review of the charts and radiographs of 157 consecutive patients with adult scoliosis treated with long instrumented spinal fusion. PJK was defined by a proximal junctional angle greater than 108 and at least 108 greater than the corresponding preoperative measurement. Radiographic measurements included sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL) and pelvic incidence (PI) on preoperative, immediate postoperative and at follow-up. Bone mineral density (BMD), Body mass index (BMI), age, sex, instrumentation type, surgery type, and fusion to sacrum were reviewed. Postoperative SRS outcome scores and Oswestry Disability Index (ODI) were also evaluated. PJK was graded by the severity and type. Means were compared with Student's t test and χ2 test. P value of less than 0.05 with confidence interval 95% was considered significant. RESULTS: The average age was 46.9 years (22-81 years) and the average Follow-up was 4.3 years (2-12 years). PJK occurred in 32 patients (20%) and were mostly classified as 1A (Ligamentous & mild) deformity. The SRS outcome scores and ODI did not demonstrate significant differences between PJK group and non-PJK group, four patients had additional surgeries performed for local pain. Fusion to the sacrum and posterior fusion with segmental instrumentation were significant risk for PJK (P = 0.03, P < 0.01). BMD, BMI, age, sex, and instrumentation type showed no difference. Eighty-four percent of PJK group was associated with TK 1 LL 1 PI .458 or preoperation to postoperation SVA more than 50 mm vs. 6.4% of non-PJK group (P < 0.01, P < 0.01). CONCLUSION: Despite the occurrence of PJK in 20% of adult scoliosis patients undergoing long fusion, no significant differences were found in SRS outcome scores and ODI in PJK and non-PJK patients. Fusion to the sacrum and posterior fusion with segmental instrumentation were identified as risk factors. PJK can be minimized by post-operative normalization of global sagittal alignment. A simplified classification based in severity type of PJK showed the majority in class 1A (ligamentous lesion and mild deformity).

Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis.

STUDY DESIGN A retrospective case series of surgically treated patients with adult scoliosis. OBJECTIVE The purpose of this study was to evaluate the incidence, risk factors, and natural course of proximal junctional kyphosis (PJK) in a long-term follow-up of patients with adult idiopathic scoliosis undergoing long instrumented spinal fusion. SUMMARY OF BACKGROUND DATA Although recent reports have showed the prevalence, clinical outcomes, and the possible risk factors of PJK, quite a few reports have showed long-term follow-up outcome. MATERIALS AND METHODS This is a retrospective review of the charts and radiographs of 76 consecutive patients with adult scoliosis treated with long instrumented spinal fusion. Radiographical measurements and demographic data were reviewed on preoperation, immediate postoperation, 2 years postoperation, 5 years postoperation, and at follow-up. Postoperative Scoliosis Research Society scores and Oswestry Disability Index were also evaluated. Means were compared with Student t test. A P value of less than 0.05 with 95% confidence interval was considered significant. RESULTS The mean age was 48.8 years (range, 23-75 yr) and the average follow-up was 7.3 years (range, 5-14 yr). PJK has been identified in 17 patients. The Scoliosis Research Society and Oswestry Disability Index did not demonstrate significant differences between PJK group and non-PJK group; 2 patients had additional surgeries performed for local pain. Seventy-six percent of PJK has been identified within 3 months after surgery. Despite the fact that 53% of total degree of PJK was progressed within 3 months after surgery, PJK continuously progressed to the final follow-up. Pre-existing low bone mineral density, posterior spinal fusion (PSF), fusion to sacrum, inappropriate global spine alignment, and greater sagittal vertical axis change were identified as significant risk factors for PJK (P = 0.04, P < 0.001, P = 0.02, P < 0.0001, and P = 0.01). CONCLUSION In a long-term review of minimum 5 years, 76% of PJK occurred within 3 months after surgery. Pre-existing low bone mineral density, PSF, fusion to the sacrum, inappropriate global spine alignment, and greater sagittal vertical axis change were significant risk factors for PJK. Careful long-term follow-up should be done for a patient with PJK.

Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up

Spinal fusion surgery is currently recommended when curve magnitude exceeds 40–45 degrees. Early attempts at spinal fusion surgery which were aimed to leave the patients with a mild residual deformity, failed to meet such expectations. These aims have since been revised to the more modest goals of preventing progression, restoring 'acceptability' of the clinical deformity and reducing curvature. In view of the fact that there is no evidence that health related signs and symptoms of scoliosis can be altered by spinal fusion in the long-term, a clear medical indication for this treatment cannot be derived. Knowledge concerning the rate of complications of scoliosis surgery may enable us to establish a cost/benefit relation of this intervention and to improve the standard of the information and advice given to patients. It is also hoped that this study will help to answer questions in relation to the limiting choice between the risks of surgery and the "wait and see – observation only until surgery might be recommended", strategy widely used. The purpose of this review is to present the actual data available on the rate of complications in scoliosis surgery. Search strategy for identification of studies; Pub Med and the SOSORT scoliosis library, limited to English language and bibliographies of all reviewed articles. The search strategy included the terms; 'scoliosis'; 'rate of complications'; 'spine surgery'; 'scoliosis surgery'; 'spondylodesis'; 'spinal instrumentation' and 'spine fusion'. The electronic search carried out on the 1st February 2008 with the key words "scoliosis", "surgery", "complications" revealed 2590 titles, which not necessarily attributed to our quest for the term "rate of complications". 287 titles were found when the term "rate of complications" was used as a key word. Rates of complication varied between 0 and 89% depending on the aetiology of the entity investigated. Long-term rates of complications have not yet been reported upon. Scoliosis surgery has a varying but high rate of complications. A medical indication for this treatment cannot be established in view of the lack of evidence. The rate of complications may even be higher than reported. Long-term risks of scoliosis surgery have not yet been reported upon in research. Mandatory reporting for all spinal implants in a standardized way using a spreadsheet list of all recognised complications to reveal a 2-year, 5-year, 10-year and 20-year rate of complications should be established. Trials with untreated control groups in the field of scoliosis raise ethical issues, as the control group could be exposed to the risks of undergoing such surgery.

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Rate of complications in scoliosis surgery – a systematic review of the Pub Med literature

Object Appreciation of the optimal management of skeletally mature patients with spinal deformities requires understanding of the natural history of the disease relative to expected outcomes of surgical intervention. Appropriate outcome measures are necessary to define the surgical treatment. Unfortunately, the literature lacks prospective randomized data. The majority of published series report outcomes of a particular surgical approach, procedure, or surgeon. The purpose of the current study was to systematically review the present spine deformity literature and assess the available data on clinical and radiographic outcome measurements. Methods A systematic review of MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery,” “adult spine deformity surgery,” “outcomes,” and “complications.” Exclusion criteria included follow-up shorter than 2 years and mean patient age younger than 18 years. Data on major c...

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Adult scoliosis surgery outcomes: a systematic review.

Study design Longitudinal cohort. Objective To determine the minimum clinically important difference (MCID) of the Scoliosis Research Society (SRS)-22 Appearance, Activity, and Pain domains in patients with adolescent idiopathic scoliosis undergoing surgical correction of their spinal deformity. Summary of background data The MCID, a threshold of improvement that is clinically relevant to the individual patient, is increasingly used to evaluate treatment effectiveness. MCID values for the SRS-22 domains have not been determined. Methods Patients with adolescent idiopathic scoliosis who underwent surgical correction and had completed SRS-22 before operation and the SRS-30 and Scoliosis Appearance Questionnaire (SAQ) at 1 year after operation from a multicenter database for pediatric scoliosis were identified. The SAQ is a modification of the Walter Reed Visual Assessment Scale and is used to assess the patient's perception of their spinal deformity. Paired sample t tests were used to compare preoperative and 1-year postoperative scores. Spearman correlations were used to evaluate associations between domain scores and summed responses to anchors for Appearance, Activity, and Pain. MCID values for the SRS-22 domains were determined using receiver operating characteristic curve analysis, with summed responses to anchor questions 23 to 30 of the SRS-30 and items 26 and 32 of the SAQ. Results There were 735 women and 152 men with a mean age of 14.3 years and a mean Cobb angle of 53°. There was a statistically significant difference between paired preoperative and 1-year SRS domain scores. Analysis of variance showed a statistically significant difference between the summed responses to the anchors. The MCID was 0.20 for the Pain domain (area under the curve [AUC] = 0.723), 0.08 for Activity (AUC = 0.648), and 0.98 for Appearance (AUC = 0.629). The MCID for activity was less than the standard error of measurement. Conclusion The MCID for the Pain domain was 0.20 and 0.98 for Appearance. Because these patients were generally in good health, a minimal though significant change in activity was observed, such that the calculated MCID was within the measurement error. As expected, the largest and most important change was in the Appearance domain. Future studies are needed to determine the MCID for the mental domain and the total SRS score and to further validate the MCID values in this study.

The minimum clinically important difference in Scoliosis Research Society-22 Appearance, Activity, And Pain domains after surgical correction of adolescent idiopathic scoliosis.

Study design Tricenter retrospective cohort study of 72 patients who underwent posterior correction of Lenke 1 adolescent idiopathic scoliosis (AIS). Each center represented a single surgeon using only one type of construct. Objective Compare the initial postoperative and 2-year follow-up correction of Lenke 1 AIS curves, after accounting for the preoperative flexibility of the curves. Summary of background data There are multiple reports in literature of the enhanced posterior corrective ability of the pedicle screw in the treatment of AIS. Unfortunately, none of these reports took into account the preoperative flexibility of the curve. It stands to reason that rigid curves will not correct as much as flexible curves irrespective of the nature of the construct. Methods Groups were as follows: Group 1 (proximal and distal hooks and segmental intraspinous collar button wires), 24 patients; Group 2 (proximal hooks, distal screws, and apical sublaminar wires), 23 patients; and Group 3 (pedicle screws only), 25 patients. The postoperative correction percentage was expressed as a ratio of the preoperative flexibility and was termed Cincinnati correction index (CCI). Mathematically speaking the CCI equals (postoperative correction/preoperative erect Cobb angle) divided by (supine bending preoperative correction/preoperative erect Cobb angle). The postoperative sagittal correction was also measured. Results CCI 2 (at 2-year follow-up) for Group 1 was 1.71, for Group 2 was 1.34, and for Group 3 was 1.41. The differences were not statistically significant. Within Group 1, however, there was a statistically significant difference between CCI (1.95) and CCI 2 (1.71), indicating a statistically significant loss of correction over 2 years. However, in terms of absolute values, there was only a 4 degree (average) difference between the initial and the 2-year postoperative Cobb measurement, rendering the loss off correction clinically insignificant. No such statistically or clinically significant differences were noted within Groups 2 and 3. Group 1 and Group 3 constructs further lordosed the curve by 8 degrees and 11 degrees, respectively, whereas the Group 2 construct retained or marginally increased the preoperative kyphosis. Conclusion The Group 3 (pedicle screw only) construct did not give an enhanced correction of Lenke 1 AIS, when the preoperative flexibility of the curve was considered. Also, contrary to popular belief, the pedicle screw construct has a lordosing effect on the thoracic spine. Therefore, we think that there is no significant advantage in using a relatively expensive pedicle screw construct in the correction of Lenke 1 AIS.

A pedicle screw construct gives an enhanced posterior correction of adolescent idiopathic scoliosis when compared with other constructs: myth or reality.

Study Design. Thromboembolic disease (TED) after anterior/posterior spinal reconstructions was prospectively evaluated in 66 consecutive patients. Objective. Determine the incidence of TED after anterior/posterior spinal reconstruction. Summary of Background Data. Few studies have examined the rate of TED after potentially high-risk combined anterior/posterior reconstructions. Magnetic resonance venography (MRV) is more effective at detecting pelvic deep venous thrombosis (DVT) than conventional screening, but has not been used in these patients. Methods. We undertook a prospective cohort study of 66 consecutive adult patients (mean, 52.7 ± 9.6 years) undergoing combined anterior/posterior spinal reconstructions for spinal deformity. All patients received only mechanical DVT prophylaxis. After surgery, MRV and bilateral lower extremity Doppler ultrasounds were obtained to screen for DVT, and contrast-enhanced spiral computed tomography scans were obtained for clinical suspicion of pulmonary embolism (PE). Results. The total incidence of postoperative TED was 13.6% (9 patients). The overall rate of DVT was 9.1% (6 patients), one-third occurring in the pelvis. PE developed in 7.6% (5 patients). In 2 patients, PE developed less than 48 hours after positive dopplers. In 3 patients, PE developed despite negative screening studies. Right-sided thoracoabdominal approaches were associated with an increased risk of developing DVT (P = 0.03, Odds Ratio 9.8), PE (P = 0.01, Odds Ratio 20), and TED (P = 0.004, Odds Ratio 12). Conclusion. We report a high rate of TED after extensive anterior/posterior spinal reconstructions, for which a right-sided thoracoabdominal approach is an independent risk factor and screening ineffective at preventing PE. These patients should be considered at high risk for postoperative TED.

Thromboembolic disease after combined anterior/posterior reconstruction for adult spinal deformity: a prospective cohort study using magnetic resonance venography.

Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome.

BACKGROUND CONTEXT: To date, no study has critically examined the radiographic characteristics of the lumbar curve after selective thoracic fusion for the adult idiopathic scoliosis patient population.

Gina Charles

Papers

A pedicle screw construct gives an enhanced posterior correction of adolescent idiopathic scoliosis when compared with other constructs: myth or reality.

Thromboembolic disease after combined anterior/posterior reconstruction for adult spinal deformity: a prospective cohort study using magnetic resonance venography.

Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome.

Clinical Studies Lumbar curve response to selective thoracic fusion in adult idiopathic scoliosis

Lumbar curve response to selective thoracic fusion in adult idiopathic scoliosis.