Study Design.This study is a retrospective review of 752 patients with adult spinal deformity enrolled in a multicenter prospective database in 2002 and 2003. Patients with positive sagittal balance (N = 352) were further evaluated regarding radiographic parameters and health status measures, includ

The Impact of Positive Sagittal Balance in Adult Spinal Deformity

Study design This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. Objectives The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. Summary of background data Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. Methods The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. Results The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. Conclusions This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

Correlation of radiographic parameters and clinical symptoms in adult scoliosis

STUDY DESIGN Prospective radiographic and clinical analysis. OBJECTIVE Investigate the relationship between spino-pelvic parameters and patient self reported outcomes on adult subjects with spinal deformities. SUMMARY OF BACKGROUND DATA It is becoming increasingly recognized that the study of spinal alignment should include pelvic position. While pelvic incidence determines lumbar lordosis, pelvic tilt (PT) is a positional parameter reflecting compensation to spinal deformity. Correlation between plumbline offset (sagittal vertical axis [SVA]) and Health Related Quality of Life (HRQOL) measures has been demonstrated, but such a study is lacking for PT. METHODS This prospective study was carried out on 125 adult patients suffering from spinal deformity (mean age: 57 years). Full-length free-standing radiographs including the spine and pelvis were available for all patients. HRQOL instruments included: Oswestry Disability Index, Short Form-12, Scoliosis Research Society. Correlation analysis between radiographic spinopelvic parameters and HRQOL measures was pursued. RESULTS Correlation analysis revealed no significance pertaining to coronal plane parameters. Significant sagittal plane correlations were identified. SVA and truncal inclination measured by T1 spinopelvic inclination (T1-SPI) (angle between T1-hip axis and vertical) correlated with: Scoliosis Research Society (appearance, activity, total score), Oswestry Disability Index, and Short Form-12 (physical component score). Correlation coefficients ranged from 0.42 < r < 0.55 (P < 0.0001). T1-SPI revealed greater correlation with HRQOL compared to SVA. PT showed correlation with HRQOL (0.28 < r < 0.42) and with SVA (r = 0.64, P < 0.0001). CONCLUSION This study confirms that pelvic position measured via PT correlates with HRQOL in the setting of adult deformity. High values of PT express compensatory pelvic retroversion for sagittal spinal malalignment. This study also demonstrates significant T1-SPI correlation with HRQOL measures and outperforms SVA. This parameter carries the advantage of being an angular measurement which avoids the error inherent in measuring offsets in noncalibrated radiographs.

Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity.

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.

A new method for the treatment of scoliosis is described in which a metal system of rods and hooks is implanted, and distraction and compression forces applied, to correct the curve and stabilize the treated segments in the corrected position by skeletal fixation. The technique and principles of this method of treatment and a summary of the preliminary results are given.

JBJS classics: Treatment of scoliosis: Correction and internal fixation by spine instrumentation

Study design Retrospective study. Objectives To report a technique of vertebral column resection through a single posterior approach and its preliminary results in the treatment of moderate to severe spinal deformities with limited flexibility. Summary of background data Vertebral column resection is a formidable operation reserved for moderate to severe deformities with limited flexibility. The authors devised a technique of vertebral column resection through a single posterior approach that offers significant advantages over the anterior-posterior vertebral column resection. Methods Seventy spinal deformity patients treated by posterior vertebral column resection were reviewed. Minimum follow-up was 2 years (range 2-3.3 years). There were 34 males and 36 females with a mean age of 27.4 years at the time of the operation. Etiologic diagnoses were adult scoliosis in 7, congenital kyphoscoliosis in 38, and postinfectious kyphosis in 25. The surgery consisted of temporary stabilization of the vertebral column with segmental pedicle screw fixation, resection of the vertebral column at the apex of the deformity via the posterior route, followed by gradual deformity correction and global fusion. Results The total number of resected vertebrae was 143: 76 in thoracic and 67 in lumbar. Mean operation time was 4 hours, 31 minutes with average blood loss of 2333 mL. The deformity correction was 61.9% in the coronal plane and 45.2 degrees in the sagittal plane. Complications were encountered in 24 patients: 2 complete cord injuries in severe adult scoliosis and thoracic kyphosis patient who had significant preoperative cord compromise, 6 hematomas, 4 root injuries (all incomplete), 5 fixation failures, 2 infections, and 5 hemopneumothoraxes. Conclusions Posterior vertebral column resection is an effective alternative for moderate to severe deformities with limited flexibility. However, it is a technically demanding and exhausting procedure with possible risks for major complications.

Posterior vertebral column resection for severe spinal deformities.

STUDY DESIGN A prospective study. OBJECTIVES To introduce a new technique, direct vertebral rotation, and to compare the surgical results of direct vertebral rotation with those of simple rod derotation. SUMMARY OF BACKGROUND DATA Pedicle screw fixation with a simple rod derotation maneuver enables a powerful coronal and sagittal plane correction in scoliosis surgery. However, the ability of achieving rotational correction is still unclear. METHODS Thirty-eight adolescent idiopathic scoliosis patients treated with segmental pedicle screw fixation were analyzed. The first group (n = 17) was treated by direct vertebral rotation; the second group (n = 21) was treated by simple rod derotation. All patients had a minimum follow-up of 2 years. Having similar preoperative curve patterns, both groups were evaluated for the deformity correction, lower instrumented vertebral tilt, and spinal balance. Apical vertebral rotation was evaluated by computed tomography scans. Surgical techniques of direct vertebral rotation were as follows: a precontoured rod was inserted into segmental screws on the concave side in thoracic scoliosis; a simple rod derotation was performed; and then the screws on the juxta-apical vertebrae, both on concave and convex sides, were rotated opposite direction to the rod derotation. Then, all the screws were sequentially tightened. RESULTS In the direct vertebral rotation group, the average preoperative apical vertebral rotation of 16.7 degrees was corrected to 9.6 degrees, showing 42.5% correction, whereas in the simple rod derotation group, the correction was negligible from 16.1 degrees to 15.7 degrees (2.4%). In the direct vertebral rotation group, the average preoperative thoracic curve of 55 degrees was corrected to 12 degrees (79.6%), and the lumbar curve of 39 degrees was corrected to 7 degrees (80.5%). In the simple rod derotation group, the preoperative thoracic curve of 53 degrees was corrected to 17 degrees (68.9%), and the lumbar curve of 39 degrees was corrected to 16 degrees (62.2%). The average lower instrumented vertebral tilt correction was 80.6% and 66.3% in the directvertebral rotation and the simple rod derotation group, respectively. There were statistically significant differences in the coronal curve, lower instrumented vertebral tilt, and rotational correction (P < 0.05, Mann-Whitney U test). Thoracic kyphosis was improved in both groups. CONCLUSIONS Segmental pedicle screw fixation with "direct vertebral rotation" showed better rotational and coronal correction than "simple rod derotation."

Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis.

Study design Radiographic analysis was performed retrospectively. Outcomes and complications were collected prospectively. Objectives To assess complications after posterior fusion and instrumentation for degenerative lumbar scoliosis, to determine risk factors of complications, and to analyze the clinical outcomes of surgery. Summary of background data The complications after degenerative lumbar scoliosis surgery have reported to be high. Risk factors for developing complications are unknown. Methods Forty-seven patients (average age, 66.6 years; range, 48-83 years) with degenerative lumbar scoliosis undergoing posterior fusion and instrumentation were analyzed. Seven patients had additional posterior lumbar interbody fusion at the lumbosacral junction. The average number of levels fused was 4.7 +/- 2.2 segments. We evaluated the early perioperative ( Results There were 14 early perioperative complications and 18 late complications. There was 1 case of mortality by pulmonary embolism. Early complications included ileus, urinary tract infection, transient delirium, superficial infection, and neurologic deficit. Late complications included adjacent segment diseases, pseudarthrosis, and loosening of screws. Adjacent segment disease developed at the proximal segment in 10 patients and at the distal segment in 5 patients. Pseudarthrosis was noted at the lumbosacral junction in 2 patients. Revision surgery was performed in 7 patients. Older patients (>65 years) had the tendency to increase early complications without statistical difference (P = 0.053). Excessive intraoperative blood loss was the most significant risk factor for the development of early perioperative complications, and number of levels fused was related to blood loss. Operative time and multiple medical comorbidities were not associated with higher complication rate. There were no specific factors related to the development of late complications. Conclusion The complication rate after posterior fusion and instrumentation for degenerative lumbar scoliosis was 68%. Abundant blood loss was a significant risk factor for early perioperative complications. The improvement of Oswestry disability index was less in patients with late complications.

Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis.

Study design Retrospective study. Objective To report on the technique and results of posterior vertebral column resection (PVCR) for severe rigid scoliosis. Summary of background data The treatment of severe rigid scoliosis is a demanding surgical challenge. Conventional procedures such as combined anteroposterior instrumentation enable limited correction. In rigid scoliosis, vertebral column resection is a better option for accomplishing translation of spinal column. PVCR is performed through a single posterior approach. Methods A total of 16 patients with scoliosis (average age 29 years) subjected to PVCR were retrospectively reviewed after a minimum follow-up of 2 years (range 2-6.8). The indication for PVCR was scoliosis more than 80 degrees , with flexibility less than 25%. The radiographic parameters were evaluated, and clinical records were reviewed. Results The number of vertebrae removed averaged 1.3, and 21 total (15 thoracic and 6 lumbar). Average fusion extent was 10.6 vertebrae. The mean preoperative scoliosis of 109.0 degrees was corrected to 45.6 degrees (59% correction) at the most recent follow-up, and the minor curve of 59.3 degrees was corrected to 29.2 degrees (51% correction). The mean preoperative coronal imbalance of 4.0 cm was improved to 1.0 cm at the most recent follow-up, and sagittal imbalance of 4.2 cm was improved to 1.6 cm. Complications were encountered in 4 patients, including 1 complete paralysis, 1 hematoma, 1 hemopneumothorax, and 1 proximal junctional kyphosis. Conclusions PVCR is an effective alternative for severe rigid scoliosis. It is a highly technical procedure and should only be performed by an experienced surgical team.

Posterior Vertebral Column Resection for Severe Rigid Scoliosis

STUDY DESIGN Scoliosis patients were prospectively x-rayed in three positions with independent analysis OBJECTIVES To determine if one positioning technique provides superior visualization of critical landmarks (C7, T2, T12, L5-S1) and to determine any position dependent variations in regional measures or sagittal balance SUMMARY OF BACKGROUND DATA Different techniques for positioning patient's arms are used for 36" lateral radiograph with no data on relative effects METHODS A total of 25 scoliosis patients were prospectively studied with 36" lateral radiographs in three positions varying arm location (straight out, partially flexed, and the "clavicle" position) Films were analyzed independently by three surgeons Vertebral landmarks were scored for clarity; and lordosis, kyphosis, and global balance were analyzed Statistical analysis was done with a General Estimating Equations model RESULTS The overall visualization score for the clavicle position was superior to either the 60 degrees or 90 degrees positions (clavicle vs 60 degrees, P < 00001; clavicle vs 90 degrees, P < 00003) Analysis of vertebral landmarks showed significantly better visualization of T2 with clavicle versus 90 degrees (P < 0047), better visualization of T12 with clavicle versus either 60 degrees (P < 0006) or 90 degrees (P < 0049), and better visualization of L5-S1 with clavicle versus 90 degrees (P < 002) Regional measures showed no differences, but sagittal balance was significantly more positive in the 60 degrees position than either clavicle (P < 004) or 90 degrees (P < 0015) CONCLUSIONS The clavicle position for obtaining lateral 36" radiographs produces significantly better overall visualization of critical vertebral landmarks Regional measures do not differ between the three positions, but global balance is more positive with the 60 degrees position Clinically, the clavicle position may result in more accurate radiographic measures and may minimize repeated radiograph exposures

Se-Il Suk

Papers

Posterior vertebral column resection for severe spinal deformities.

Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis.

Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis.

Posterior Vertebral Column Resection for Severe Rigid Scoliosis

Is there an optimal patient stance for obtaining a lateral 36" radiograph? A critical comparison of three techniques.