Adult degenerative scoliosis: comparison of patient-rated outcome after three different surgical treatments

S1 vertebral bone quality score independently predicts pedicle screw loosening following surgery in patients with adult degenerative scoliosis

BACKGROUND CONTEXT

MRI-based vertebral bone quality (VBQ) score is an effective predictor of pedicle screw loosening after lumbar fusion surgery and has been recognized as a valuable tool for assessing preoperative bone quality. Due to the lateral curvature of lumbar spine of degenerative scoliosis, accurate measurement of VBQ score by conventional measurement methods that capture MRI signal intensity at L1-4 may be limited under certain conditions. To this end, a new simplified S1 VBQ score method has been proposed, which is comparable to the previous L1-4 VBQ score or S1 Hounsfield unit (HU) value, and has high accuracy and reliability.

PURPOSE

To evaluate the predictive value of MRI-based S1 VBQ score for pedicle screw loosening following surgery for adult degenerative scoliosis (ADS).

STUDY DESIGN/SETTING

Retrospective single-center cohort.

PATIENT SAMPLE

We reviewed 92 patients who underwent posterior lumbar interbody fusion (PLIF) with pedicle screw fixation for ADS between January 2017 and January 2020.

OUTCOME MEASURES

Association between S1 VBQ score and pedicle screw loosening following surgery for ADS.

METHODS

We retrospectively reviewed the records of all patients who performed PLIF between January 2017 and January 2020. The clear zone around pedicle screws≥1 mm can be identified as screw loosening. The S1 VBQ score is calculated from the S1 central-based noncontrast T1-weighted magnetic resonance imaging (MRI). The signal intensity (SI) of the cerebrospinal fluid (CSF) was then measured using ROI placed at the L3 level to normalize the results. Multivariate logistic regression analysis was performed to identify independent risk factors for screw loosening. Then, constructed a receiver operating characteristic (ROC) curve and determined the threshold (cut-off) of VBQ score with high sensitivity and specificity based on Youden Index.

RESULTS

A total of 92 patients were included, including 34 males and 58 females. The mean age of the patients was 61.23±1.23 years old. At 1-year follow-up, the screw loosening rate was 56.5% (52/92). The age and levels of fixation were higher in the loosening group than in the nonloosening group (p=.036, p=.025). Patients in the loosening group had a greater VBQ score compared to patients in the nonloosening group (3.31±0.41 vs 3.01±0.28, p=.001). Multivariate logistic regression analysis showed that advanced age (OR, 1.090; 95% CI 1.005-1.183; p=.039) and higher VBQ score (OR, 5.778; 95% CI 2.889-16.177; p=.001) were independent risk factors for screw loosening. In addition, the ROC curve were created to assess the role of VBQ score as predictors of screw loosening with a diagnostic accuracy of 74.6% (95% CI 64.2%-85.1%).The most suitable threshold for the VBQ score as determined by the Youden Index was 3.175 (sensitivity: 76.0%, specificity: 83.3%).

CONCLUSIONS

Higher S1 VBQ score was significantly associated with pedicle screw loosening following surgery for ADS. The S1 VBQ score can be used as an effective preoperative predictor, which has the potential clinical application.

Lasso Analysis of Gait Characteristics and Correlation with Spinopelvic Parameters in Patients with Degenerative Lumbar Scoliosis

PURPOSE

This study quantifies the gait characteristics of patients with degenerative lumbar scoliosis (DLS) and patients with simple lumbar spinal stenosis (LSS) by means of a three-dimensional gait analysis system, aiming to determine the image of spinal deformity on gait and the correlation between spinal-pelvic parameters and gait characteristics in patients with DLS to assist clinical work.

METHODS

From June 2020 to December 2021, a total of 50 subjects were enrolled in this study, of whom 20 patients with DLS served as the case group and 30 middle-aged and elderly patients with LSS were selected as the control group according to the general conditions (sex, age, and BMI) of the case group. Spinal-pelvic parameters were measured by full-length frontal and lateral spine films one week before surgery, and kinematics were recorded on the same day using a gait analysis system.

RESULTS

Compared to the control group, DLS patients exhibited significantly reduced velocity and cadence; gait variability and symmetry of both lower limbs were notably better in the LSS group than in the DLS group; joint ROM (range of motion) across multiple dimensions was also lower in the DLS group; and correlation analysis revealed that patients with a larger Cobb angle, T1PA, and higher CSVA tended to walk more slowly, and those with a larger PI, PT, and LL usually had smaller stride lengths. The greater the PI-SS mismatch, the longer the patient stayed in the support phase. Furthermore, a larger Cobb angle correlated with worse coronal hip mobility.

CONCLUSIONS

DLS patients demonstrate distinctive gait abnormalities and reduced hip mobility compared to LSS patients. Significant correlations between crucial spinopelvic parameters and these gait changes underline their potential influence on gait disturbances in DLS. Our study identifies a Cobb angle cut-off of 16.1 as a key predictor for gait abnormalities. These insights can guide personalized treatment and intervention strategies, ultimately improving the quality of life for DLS patients.

Which Global Sagittal Parameter Could Most Effectively Predict the Surgical Outcome for Patients With Adult Degenerative Scoliosis?

STUDY DESIGN

Retrospective study.

OBJECTIVE

To evaluate the predictive effect of the 3 global sagittal parameters (Sagittal Vertical Axis [SVA], T1 Pelvic Angle [TPA], and relative TPA [rTPA]) in the surgical outcome of patients with adult degenerative scoliosis (ADS), then to define the optimum corrective goal based on the best of them.

METHODS

117 ADS patients were included in this study and followed-up for an average of 3 years. Functional evaluation and radiographs were assessed preoperatively and postoperatively. The predictive accuracy of SVA, TPA, and relative TPA was analyzed through receiver operating characteristic (ROC) curve. The cutoff value of TPA was obtained at the maximal Youden index from ROC curve.

RESULTS

TPA most highly correlated with postoperative oswestry disability index (ODI). The best cutoff value of TPA was set at 19.3° (area under curve =0.701). TPA >19.3° was the highest risk factor in multivariate logistic regression analysis (OR = 7.124, P = 0.022). Patients with TPA <19.3° at 3 months after operation showed a better ODI than those with TPA >19.3°. Correcting TPA less than 19.3° for patients with preoperative TPA >19.3° attributed to a better health related quality of life (HRQOL) and sagittal balance at last follow-up. The formula "Postoperative TPA = 0.923 × PI - 0.241 × postoperative LL - 0.593 × postoperative SS - 2.471 (r = 0.914, r2 = 0.836, P < .001)" described the relation between SS, LL, PI, and TPA.

CONCLUSION

TPA was a useful global parameter for the prediction of postoperative HRQOL for patients with ADS. Keeping TPA <19.3° could improve the postoperative HRQOL for ADS patients with preoperative TPA >19.3°, and TPA <19.3° could be an optimum correction target for patients with ADS.

Decompression Alone in the Setting of Adult Degenerative Lumbar Scoliosis and Stenosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes.

METHODS

A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence.

RESULTS

Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%.

CONCLUSIONS

Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.

Treatment of patients with degenerative deformities of the lumbar spine using MIS technologies: analysis of 5-year results

Objective. To analyze the results of the use of minimally invasive technologies in the treatment of patients with degenerative deformity of the lumbar spine.

Material and Methods. Design: Single-center, non-randomized continuous retrospective cohort study. The level of evidence is 3b (UK Oxford, version 2009). A total of 57 patients (10 men and 47 women) were operated for degenerative scoliosis of the lumbar spine using minimally invasive techniques. The quality of life indicators using ODI, SF-36, VAS, as well as linear and angulometric parameters of the spine were studied.

Results. The age of patients ranged from 37 to 81 years (62/62 [55; 67], hereinafter the data format is mean/median [1; 3rd quartile]). In the postoperative period, patients operated on with MIS techniques showed a statistically significant decrease in pain by 4.3/4.0 [3; 6] points in the lumbar spine, and by 4.3/4.0 [3; 6] points in the legs. Quality of life indicators according to ODI improved by 24/23 [19;  29], and the level of functional adaptation according to the SF-36 questionnaire – by 18/18 [14; 21] in terms of physical parameters and by 18/20 [16; 23] in terms of mental parameters. The deformity angle in the frontal plane according to Cobb decreased by 12.9°/13.0° [10°; 17°], lumbar lordosis changed by 3.3°/2.0° [-1°; 7°], segmental angle L4–S1 – by 1.0°/0.0° [-5°; 7°], and SVA changed by -7.5/-2.0 [-29; 15] mm. As a result of minimally invasive surgical intervention, a good clinical result was obtained in correcting the scoliotic deformity angle from 17.5°/16.0° [11°; 22°] to 4.6°/4.0° [1°; 7°].

Conclusion. The study showed the effectiveness of minimally invasive surgical treatment of degenerative scoliosis of the lumbar spine with short-segment fixation, which allowed obtaining satisfactory clinical results in 93 % of cases with a minimum number of complications (7 %).

The clinical effectiveness and complications of lumbar selective fenestration and concave-side fusion (LSFCF) in degenerative lumbar scoliosis (DLS) combined with lumbar spinal stenosis (LSS)

PURPOSE

This retrospective study was performed to analyze the clinical effects and complications of LSFCF in the surgical treatment of DLS combined with lumbar spinal stenosis (LSS).

METHODS

A total of 26 eligible patients (mean age, 64.73 y; 17 men, 9 women) with DLS combined with LSS were included and LSFCF surgery was performed. An independent spine surgeon retrospectively reviewed the medical records and radiographs of all patients to evaluate surgical data and surgery-related complications. Preoperative, postoperative, and follow-up questionnaires were obtained to assess clinical outcomes.

RESULTS

The average follow-up period of this study was 20.14 ± 5.21 months. The operation time and blood loss of patients underwent LSFCF were 129.33 ± 15.74 min and 356.13 ± 21.28 ml. The clinical effects of all patients in terms of visual analogue scale (VAS) and Oswestry disability index (ODI) have been significantly improved at the final follow-up postoperatively (P < 0.05). Complications such as infection, cerebrospinal fluid leakage, nerve injury, and internal fixation failure, etc. were not observed during the follow-up period.

CONCLUSION

The LSFCF surgery is a safe and effective treatment for DLS patients combined with LSS.

Surgeons' risk perception in ASD surgery: The value of objective risk assessment on decision making and patient counselling

BACKGROUND

Surgeons often rely on their intuition, experience and published data for surgical decision making and informed consent. Literature provides average values that do not allow for individualized assessments. Accurate validated machine learning (ML) risk calculators for adult spinal deformity (ASD) patients, based on 10 year multicentric prospective data, are currently available. The objective of this study is to assess surgeon ASD risk perception and compare it to validated risk calculator estimates.

METHODS

Nine ASD complete (demographics, HRQL, radiology, surgical plan) preoperative cases were distributed online to 100 surgeons from 22 countries. Surgeons were asked to determine the risk of major complications and reoperations at 72 h, 90 d and 2 years postop, using a 0-100% risk scale. The same preoperative parameters circulated to surgeons were used to obtain ML risk calculator estimates. Concordance between surgeons' responses was analyzed using intraclass correlation coefficients (ICC) (poor < 0.5/excellent > 0.85). Distance between surgeons' and risk calculator predictions was assessed using the mean index of agreement (MIA) (poor < 0.5/excellent > 0.85).

RESULTS

Thirty-nine surgeons (74.4% with > 10 years' experience), from 12 countries answered the survey. Surgeons' risk perception concordance was very low and heterogeneous. ICC ranged from 0.104 (reintervention risk at 72 h) to 0.316 (reintervention risk at 2 years). Distance between calculator and surgeon prediction was very large. MIA ranged from 0.122 to 0.416. Surgeons tended to overestimate the risk of major complications and reintervention in the first 72 h and underestimated the same risks at 2 years postop.

CONCLUSIONS

This study shows that expert surgeon ASD risk perception is heterogeneous and highly discordant. Available validated ML ASD risk calculators can enable surgeons to provide more accurate and objective prognosis to adjust patient expectations, in real time, at the point of care.

The Comparison of Spinopelvic Parameters, Complications, and Clinical Outcomes After Spinal Fusion to S1 with or without Additional Sacropelvic Fixation for Adult Spinal Deformity: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The purpose of the study was to compare the outcomes and after spinal fusion with or without iliac screw (IS) insertion for patients with adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

The number of patients undergoing multilevel spinal stabilization for the treatment of ASD is growing. However, the selection of spinopelvic fixation for ASD patients with long fusion is controversial.

METHODS

A comprehensive literature search was performed without time restriction according to the guidelines from the Cochrane Collaboration in May 2020 using PubMed, EMBASE, and the Cochrane Library. The comparison of the two types of fixation was evaluated by spinopelvic parameters, incidence rate of complications, rate of revision, and clinical outcomes at the last follow-up.

RESULTS

The literature search identified 422 records, of which eight studies were included for meta-analysis with a total of 439 patients. All the included studies provided level III evidence. There was no significant difference in the sagittal vertical axis, pelvic incidence, the proximal junctional kyphosis rates, the pseudarthrosis rates, the revision rates, and the clinical outcomes at the last follow-up between those who receive sacrum fixation and sacropelvic fixation. Nevertheless, greater lumbar lordosis (LL) (weighted mean difference [WMD], 4.15; 95% confidence interval [CI] 2.46-5.84, P < 0.01), greater sacral slope (SS) (WMD, 2.32; 95% CI 1.21-3.43, P < 0.01), and lower rate of the distal instrumentation instability (odds ratio, 0.25; 95% CI 0.10-0.61, P = 0.002) were observed in IS group between the comparison.

CONCLUSION

The clinical outcomes in the IS group were similar to those in the non-IS group, but the application of the IS significantly restored LL, prevented decompensation, and reduced the occurrence of the distal instrumentation instability. Therefore, the IS may be a good choice for the operative treatment of ASD patients with sagittal malalignment and other risks of lumbosacral fracture, metal breakage, and screw pullout.Level of Evidence: 3.

Surgical Management of Degenerative Lumbar Scoliosis Associated With Spinal Stenosis: Does the PI-LL Matter?

STUDY DESIGN

Retrospective observational cohort study.

OBJECTIVES

To compare the benefits of long and short fusion treatments, and to identify factors potentially aiding surgeons' decision making about the surgical management of degenerative lumbar scoliosis associated with spinal stenosis (DLSS).

SUMMARY OF BACKGROUND DATA

The comparative effectiveness of long and short segment fusion for the treatment of DLSS remains controversial.

METHODS

Fifty-three patients with symptomatic DLSS managed by posterior-only fusion surgery were enrolled in this study. Twenty patients underwent short fusion (fewer than two segments), and 33 patients had more than three segments fused. The radiological outcomes were assessed by radiography. Health-related quality of life data, including visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, were collected at all preoperative and follow-up visits.

RESULTS

The short and long fusion groups showed significant differences in the change in the Cobb angle (4.2° vs. 11.2°), lumbar lordosis (3.9° vs. 11.5°), and pelvic incidence minus the lumbar lordosis angle (PI - LL; 3.2° vs. 11.2°). Both the short and long fusion achieved significant changes in low back pain and leg pain. Patients with PI -LLs > 10° had more relief of low back pain after long fusion (VAS 4.0 ± 2.0) than after short fusion (VAS 2.6 ± 1.7). Patients with PI - LLs > 10° showed significantly improved walking ability after long fusion (ODI 1.0 ± 0.8). The improvement in standing ability after short fusion was greater when PI - LL ≤ 10°(ODI 0.9 ± 0.6).

CONCLUSION

Long segment fusion can relieve low back pain better and improve walking ability when PI-LL is mismatched, whereas short segment fusion is more advantageous in improving standing ability in cases of more balanced sagittal spinopelvic alignment.

LEVEL OF EVIDENCE

3.

A hybrid therapeutic approach for decreasing postoperative complications in patients with adult lumbar degenerative scoliosis

To decrease postoperative complications in patients with adult lumbar degenerative scoliosis (ALDS), short-segment fusion surgery was used in this study. However, the incidence of adjacent segment disease was found to be remarkable. Therefore, we applied the hybrid treatment (short-segment fusion for responsibility levels plus nonfusion stabilization of lumbar segments, which was called the Wallis system, for the proximal level) to patients enrolled into this study. The purpose of this study was to investigate the feasibility of a novel hybrid therapeutic approach for treating patients with ALDS.From January 2011 to January 2017, a retrospective study was conducted consisting of 16 patients with ALDS who were treated with hybrid treatment. All patients were treated with short-segment decompression and fusion for responsibility levels and nonfusion stabilization of lumbar segments for the proximal levels. The imaging outcomes were evaluated preoperatively and at the time of follow-up.The mean visual analog score for back pain decreased from 6.1 ± 2.0 preoperatively to 2.1 ± 0.7 at 2-year follow-up (P < .05), and the mean visual analog score for leg pain reduced from 8.1 ± 0.6 preoperatively to 1.3 ± 0.8 at 2-year follow-up (P < .05). The Oswestry disability index scores improved from 65.4 ± 16.3% preoperatively to 18.3 ± 5.6% at 2-year follow-up (P < .05). The mean Cobb angle was 22.1 ± 6.2° preoperatively, and 13.8 ± 6.8° at 2-year follow-up (P < .05). The lumbar lordosis changed from -40.4 ± 14.8° to -43.5 ± 11.2° at 2-year follow-up (P < .05). Solid fusion was achieved in all the patients, and no incidence of adjacent segment disease was noted as well.The proposed hybrid treatment for patients with ALDS can achieve favorable clinical outcomes and a lower incidence of ALDS. However, the correction of deformity is still limited that highlights the necessity of further study.

Comparative Three-Dimensional Finite Element Analysis of 4 Kinds of Pedicle Screw Schemes for Treatment of Adult Degenerative Scoliosis

Background

This study aimed to evaluate the biomechanical stress of the internal fixation screws and vertebral bodies after the full-segment, interval, key vertebral, and strategy pedicle screw fixations under 7 work conditions in a patient with adult degenerative scoliosis (ADS) using finite elements (FE) analysis.

Material/Methods

A patient with ADS underwent internal fixation by pedicle screws after posterior incision in combination with subtotal laminectomy decompression and bone graft fusion, and received thin-layer computed tomography (CT) spine scanning at T12–L5. The CT data were used to constitute three-dimensional FE full-segment, interval, key vertebral, and strategic pedicle screw models. The stress of each screw-rod system under different working conditions was evaluated.

Results

Forward flexion, backward extension, lateral flexion, and rotation greatly increased the force of the pedicle screw systems. The maximum stress of the screw-rods was the lowest in the full-segment model under almost all the working conditions except for the upright situation. The maximum stress of the vertebral bodies was the minimum in the strategic model under all the 7 working conditions, followed by that in the key vertebra and full-segment models.

Conclusions

Collectively, the strategic and key vertebra pedicle screw schemes can decrease the biomechanical stress of screw-rod systems and vertebral bodies, which is close to the full-segment scheme. Our results may help explore the optimal surgical means for pedicle screw fixation for ADS patients, which can maximally reduce the risk of screws-related postoperative complications and simultaneously maintain a reasonable 3D orthopedic effect.

The position of the aorta relative to the spine in patients with adult degenerative scoliosis

Study design

A retrospective analysis was conducted to analyze the position of the aorta by MRI in patients with adult degenerative scoliosis.

Objective

This study aimed to investigate the relative anatomic positions of the aorta and spine in patients with adult degenerative scoliosis (ADS).

Summary of background data

Aorta injury is a rare complication of spinal surgeries. However, there would be a disastrous consequence once it happened. Therefore, knowing about the position of aorta is of great importance.

Methods

A retrospective analysis was performed in 90 patients with ADS and 132 participants without spine deformity. ADS patients were divided into several groups such as left scoliosis, left scoliosis with thoracolumbar kyphosis, right scoliosis, and right scoliosis with thoracolumbar kyphosis. The aorta-vertebrae angle (α) and aorta-vertebrae distance (d) in each level of T12–L4 were measured by using a Cartesian coordinate system. t test of independent samples was performed, α and d were compared, and Pearson correlation analysis was employed for α, d, and X-ray radiographic measurements.

Result

The changes of α were not statistically significant (P > 0.05) in LS and LKS groups but d (P < 0.05) was longer in LKS group compared with the control group. In the right malformed group, there was no significant change in the angle (P > 0.05) in the abdominal aorta but longer d (P < 0.05) than the normal group. There was longer d in the RKS group compared with the RS group (P < 0.05). Pearson correlation analysis showed that there was a positive correlation between d and TLK (r = 0.439, P < 0.05).

Conclusion

In patients with ADS, a relative normal position is maintained between the aorta and vertebrae. While the aorta is slightly away from the left pedicle in RS patients and farther away in patients with kyphosis, the angle of kyphosis would become bigger and d becomes longer. Therefore, the surgeons should be aware of the changes of the aorta position to avoid the disastrous vessel injuries.

Curve progression in de novo degenerative lumbar scoliosis combined with degenerative segment disease after short-segment fusion

PURPOSE

To validate the reliability of Berjano and Lamartina classification system of surgical planning in cases of de novo degenerative lumbar scoliosis (DNDLS) combined with degenerative segment disease and identify factors contributing to curve progression.

METHODS

Fifty-four cases of type I or II DNDLS were retrospectively reviewed. Health-related quality of life (HRQOL) was assessed using visual analogue scale (VAS) scores for the back and leg, Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scores. Radiographic parameters were obtained from X-rays. Improvements in HRQOL were confirmed by a paired t test. Changes in radiographic parameters were confirmed by paired t test and Wilcoxon signed-rank test. Clinical relevance between spinopelvic parameters and Cobb angle progression was analyzed by Spearman correlation coefficient.

RESULTS

The mean follow-up period was 36.8 ± 14.8 months. The scores taken preoperatively versus at the last follow-up were as follows: mean VAS back score, 4.5 ± 2.4 versus 1.8 ± 1.5 (p < 0.01); and mean VAS leg score, 5.2 ± 2.5 versus 1.7 ± 2.1 (p < 0.01). The ODI score improved from 25.3 ± 8.9% to 10.1 ± 5.4% (p < 0.01), whereas the mean JOA score improved from 14.3 ± 4.9 to 21.0 ± 3.7 (p < 0.01). The mean Cobb angle decreased from 17.1° ± 7.4° to 9.4° ± 4.5° postoperatively but worsened to 14.1° ± 6.4° at the last follow-up with a mean progression of 2.1° per year. Cobb angle correction was lost at a mean 2.1° ± 3.3° per year with correlation to T1 pelvic angle and sagittal vertical axis preoperatively.

CONCLUSIONS

Selective decompression and short-segment fusion were effective for treating type I and II cases DNDLS. The Cobb angle increased relative to preoperative sagittal spine alignment. These slides can be retrieved under Electronic Supplementary Material.

Comparison of long fusion terminating at L5 versus the sacrum in treating adult spinal deformity: a meta-analysis

Purpose

Choosing an optimal distal fusion level for adult spinal deformity (ASD) is still controversial. To compare the radiographic and clinical outcomes of distal fusion to L5 versus the sacrum in ASD, we conducted a meta-analysis.

Methods

Relevant studies on long fusion terminating at L5 or the sacrum in ASD were retrieved from the PubMed, Embase, Cochrane, and Google Scholar databases. Then, studies were manually selected for inclusion based on predefined criteria. The meta-analysis was performed by RevMan 5.3.

Results

Eleven retrospective studies with 1211 patients were included in meta-analysis. No significant difference was found in overall complication rate (95% CI 0.60 to 1.30) and revision rate (95% CI 0.59 to 1.99) between fusion to L5 group (L group) and fusion to the sacrum group (S group). Significant lower rate of pseudarthrosis and implant-related complications (95% CI 0.29 to 0.64) as well as proximal adjacent segment disease (95% CI 0.35 to 0.92) was found in L group. Patients in S group obtained a better correction of lumbar lordosis (95% CI − 7.85 to − 0.38) and less loss of sagittal balance (95% CI − 1.80 to − 0.50).

Conclusion

Our meta-analysis suggested that long fusion terminating at L5 or the sacrum was similar in scoliosis correction, overall complication rate, revision rate, and improvement in pain and disability. However, fusion to L5 had advantages in lower rate of pseudarthrosis, implant-related complications, and proximal adjacent segment disease, while fusion to the sacrum had advantages in the restoration of lumbar lordosis, maintenance of sagittal balance, and absence of distal adjacent segment disease.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Does sagittal imbalance impact the surgical outcomes of short-segment fusion for lumbar spinal stenosis associated with degenerative lumbar scoliosis?

BACKGROUND

The degenerative lumbar scoliosis (DLS) patients who mainly complained about neurogenic claudication due to spinal canal stenosis are well-indicated for short segment fusion (SSF) at the affecting levels. However, it is unclear whether we should consider global sagittal balance or not. The aim of this study was to evaluate the impact of sagittal balance on the surgical outcomes of degenerative lumbar scoliosis (DLS) patients who underwent SSF.

METHODS

We retrospectively reviewed 70 DLS patients who underwent SSF (less than 3 levels) and could be followed for at least 2 years. The PI-LL, PT, SVA, and T1 pelvic angle (TPA) were measured using standing whole spine X-rays preoperatively (PreO) and at final follow-up (FFU). Surgical outcomes were assessed with the improvement in Japanese Orthopaedic Association score (JOAs) for low back pain (LBP), and the level of LBP was measured using the visual analogue scale (LBP-VAS). We analysed the relationships between the radiographic parameters and the surgical outcomes.

RESULTS

We divided the patients into the three groups (poor/fair/good) based on the JOAs. The analysis with the Jonckheere-Terpstra trend test indicated that the following radiographic parameters had a significant trend with surgical outcomes in each group: (poor/fair/good; p value); PreO PI-LL (26/20/17°; P = 0.04), SVA (46/75/35.5 mm; P = 0.02), TPA (28/27/23°; p = 0.04), FFU PI-LL (33/25/8.5°; P = 0.004), SVA (93/90.5/32.5 mm; P = 0.001), and TPA (33/29/25°; P = 0.007). Additionally, LBP-VAS had a significant correlation between the three groups at final follow-up (P = 0.004). There were significant correlations between improvement in JOAs and PI-LL, SVA, and TPA both PreO and at FFU (P < 0.05).

CONCLUSIONS

Sagittal spinal imbalance and spinopelvic malalignment significantly impact the surgical outcomes of SSF for DLS. Preoperative evaluation of spinopelvic alignment and sagittal balance is of critical importance when SSF are performed for DLS patients.

Sagittal spinopelvic malalignment in degenerative scoliosis patients: isolated correction of symptomatic levels and clinical decision-making

Background

This study aims to determine if (1) loss of lumbar lordosis (LL), often associated with degenerative scoliosis (DS), is structural or rather largely due to positional factors secondary to spinal stenosis; (2) only addressing the symptomatic levels with a decompression and posterolateral fusion in carefully selected patients will result in improvement of sagittal malalignment; and (3) degree of sagittal plane correction achieved with such a local fusion could be predicted by routine pre-operative imaging.

Methods

A retrospective study design with prospectively collected imaging data of a consecutive series of surgically treated DS patients who underwent decompression and instrumented fusion at only symptomatic levels was performed. Pre- and post-operative plain radiographs and pre-operative magnetic resonance imaging (MRIs) of the spinopelvic region were analyzed. LL, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were assessed in all patients. As a requirement for the surgical strategy, all patients presented with a pre-operative PI-LL mismatch greater than 10^°. Post-operative complications were assessed.

Results

Pre-operative MRIs and lumbar extension radiographs revealed a mean LL of 42^° (range 10-66^°) and 48^° (range 20-74^°), respectively, in 68 patients (mean follow-up 29 months). LL post-operatively was corrected to a mean PI-LL of 10^°. Of patients who achieved PI-LL mismatch within 10^o on their pre-operative extension lateral lumbar radiographs, 62.5% were able to maintain a PI-LL mismatch within 10^° on their initial post-operative films. Only 37.5% were not able to achieve that mismatch on extension radiographs (p = 0.001, OR = 9.58). Similarly, 54.2% were able to achieve a PI-LL < 10^° on initial post-operative radiographs, when pre-operative MRI revealed a PI-LL mismatch within 10^°. In contrast, only 20.5% achieved that goal post-operatively if their mismatch was greater than 10^o on their MRI (p = 0.003, OR = 4.25).

Conclusion

With a decompression and instrumented fusion of only the symptomatic levels in symptomatic DS patients, we were able to achieve a PI-LL mismatch to within 10^°. The loss of LL observed pre-operatively may be largely positional rather than structural. The amount of LL correction observed immediately after surgery can be predicted from pre-operative lumbar extension radiographs and supine sagittal MRI.

The preoperative predictors for subsequent degeneration in L5-S1 disc after long fusion arthrodesis terminating at L5 in patients with adult scoliosis: focus on spinopelvic parameters

BACKGROUND

The subsequent L5-S1 disc degeneration associated with long fusion arthrodesis terminating at L5 in patients with adult scoliosis has been a common concern. However, few studies paid attention to its preoperative predictors, especially in spinopelvic parameters. The purpose of the present study was to clarify the preoperative predictors of subsequent L5-S1 disc degeneration after long fusion arthrodesis terminating at L5 in patients with adult scoliosis on spinopelvic parameters.

METHODS

In this retrospective study, we enrolled 67 patients with adult scoliosis, and the patients were divided into disc degeneration group (DD) and no disc degeneration group (NDD), based on the presence or absence of subsequent L5-S1 disc degeneration. The status of L5-S1 disc was evaluated by a modified version of radiographic classification. Characteristics and spinopelvic parameters of preoperative patients were collected as potential predictors for subsequent lumbosacral disc degeneration after long fusion arthrodesis terminating at L5 in patients with adult scoliosis. Multivariate logistic regression analysis and the receiver operating characteristic curve were used to identify the preoperative predictors, with an adjusted odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

Thirty-six patients (53.73%) with subsequent L5-S1 disc degeneration were divided into group DD (preoperative score 0.81 ± 0.57, last follow-up score 1.83 ± 0.60, P <  0.001), and the other 31 patients were divided into group NDD (preoperative and last follow-up score 0.87 ± 0.49). There was no statistical difference in preoperative score (P = 0.583) of lumbosacral disc between two groups; however, significant statistical difference showed in last follow-up score (P <  0.001). Multivariate logistic regression identified three preoperative predictors: pelvic incidence (PI) (P = 0.018), sagittal vertical axis (SVA) (P = 0.024), and sacrum-femoral distance (SFD) (P = 0.023). PI < 48.5° (OR = 0.911, 95% CI = 0.843-0.984), SVA > 4.43 cm (OR = 1.308, 95% CI = 1.036-1.649), and SFD > 5.65 cm (OR = 1.337, 95% CI = 1.041-1.718) showed satisfied accuracy for predicting subsequent L5-S1 disc degeneration.

CONCLUSION

The prevalence of the subsequent L5-S1 disc degeneration after long fusion arthrodesis terminating at L5 in patients with adult scoliosis was 57.3% (36 of 67 patients). PI < 48.5°, SVA > 4.43 cm, and SFD > 5.65 cm were preoperative predictors for the subsequent L5-S1 disc degeneration. More attention should be paid to prevent the L5-S1 disc from degeneration when these preoperative predictors exist, especially with two or more.

Sagittal radiographic parameters demonstrate weak correlations with pretreatment patient-reported health-related quality of life measures in symptomatic de novo degenerative lumbar scoliosis: a European multicenter analysis

OBJECTIVE

Previous studies have demonstrated that among patients with adult spinal deformity (ASD), sagittal plane malalignment is poorly tolerated and correlates with suboptimal patient-reported health-related quality of life (HRQOL). These studies included a broad range of radiographic abnormalities and various types of ASD. However, the clinical and radiographic characteristics of de novo degenerative lumbar scoliosis (DNDLS), a subtype of ASD, may influence previously reported correlation strengths. The aim of this study was to correlate sagittal radiographic parameters with pretreatment HRQOL in patients with symptomatic DNDLS.

METHODS

In this multicenter retrospective study of prospectively collected data, 74 patients with symptomatic DNDLS were enrolled based on anteroposterior and lateral 36-inch standing radiographs. Measurements included Cobb angle, coronal imbalance, pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis (PI−LL), T1-pelvic angle, and global tilt. HRQOL questionnaires included the Oswestry Disability Index (ODI), Scoliosis Research Society (SRS-22r), 36-item Short-Form Health Survey, and numeric rating scale (NRS) for back and leg pain. Correlations between radiographic parameters and HRQOL were assessed. Finally, HRQOL and increasing severity of sagittal modifiers (SVA, PI−LL, and PT) were evaluated.

RESULTS

Weak correlations were found between SVA and ODI (r = 0.296, p < 0.05) and PT with NRS back pain and the SRS pain domain (r = −0.260, p < 0.05, and r = 0.282, p < 0.05, respectively). Other sagittal radiographic parameters did not show any significant correlation with HRQOL. No significant differences in HRQOL were found concerning the increasing severity of PT, PI−LL, and SVA.

CONCLUSIONS

While DNDLS is a severe disabling condition, no noteworthy association between clinical and sagittal radiographic parameters was found through this study, demonstrating that sagittal radiographic parameters should not be considered the unique predictor of pretreatment suboptimal health status in this specific group of patients. Future studies addressing classification and treatment algorithms will have to take into account the existing subgroups of ASD.

Long Fusion Arthrodesis Stopping at L5 for Adult Scoliosis: Fate of L5-S1 Disk and Risk Factors for Subsequent Disk Degeneration

STUDY DESIGN

This is retrospective study.

OBJECTIVE

Our purpose is to examine the state of the L5-S1 disk after long fusion arthrodesis stopping at L5 in adult scoliosis, and to identify the risk factors for disk degeneration.

SUMMARY OF BACKGROUND DATA

The long fusion arthrodesis surgery for adult scoliosis has shown to have good clinical results. However, there is still some controversy with reference to the potential caudal extents of the fusion, that is, L5 or S1. One of the most common problems related to the L5 fusion is whether subsequent L5-S1 disk degenerations occurs because of stress concentration. In this study, 1.5-T MRI was used to evaluate the L5-S1 disk degeneration according to Pfirrmann classification.

MATERIALS AND METHODS

In total, 43 patients with adult scoliosis after posterior long fusions arthrodesis surgery were reviewed retrospectively with the average follow-up period of 4.17±1.55 years (range, 2-9 y). The 1.5 T MRI and standing long x-ray were performed preoperatively and at last follow-up visit. Clinical outcomes were evaluated according to Japanese Orthopedic Association (JOA) scores and Oswestry Disability Index (ODI).

RESULTS

Subsequent L5-S1 disk degeneration was observed in 33 patients (51.56%). Preoperative average Pfirrmann grade was 1.98±0.58, whereas during last follow-up average Pfirrmann grade was 2.63±0.83 (P<0.001). Preoperative Pfirrmann grade in patients with subsequent disk degeneration was 1.94±0.66, and in patients without subsequent disk degeneration was 2.06±0.51 (P=0.278). Greater ODI showed in patients with subsequent degeneration (P=0.008). Multivariate logistic regression analysis revealed that long follow-up period, heavy labor, and preoperative imbalance were the risk factors.

CONCLUSIONS

Subsequent L5-S1 disk degeneration was common after long fusions arthrodesis was stopped at L5. The recovery of neurological status was similar in patients with or without subsequent L5-S1 disk degeneration, whereas patients with subsequent degeneration complained more about low back pain. Patients with long follow-up period, heavy labor, and preoperative imbalance were more likely to suffer subsequent L5-S1 disk degeneration.

Predictors of Deterioration in Sagittal Balance Following Long Fusion Arthrodesis to L5 in Patients with Adult Scoliosis

Background

The aim of this study was to identify the predictors of deterioration in sagittal balance in patients with adult scoliosis following long fusion arthrodesis to L5.

Material/Methods

A retrospective clinical study included 63 patients with adult scoliosis who underwent long fusion arthrodesis to L5, between February 2005 and May 2015. Radiological imaging values included the angle of lumbar lordosis (LL), and the angle of pelvic incidence (PI). The patients were divided into two cohorts, according to the threshold of average loss of sagittal vertical axis (SVA): a cohort with stable sagittal balance (SSB) and a cohort with deteriorated sagittal balance (DSB). Multivariate logistic regression analysis and the receiver operating characteristic (ROC) curve were used to identify the predictors of clinical outcome.

Results

There were significant differences between the SSB and DSB cohorts in age (p<0.001), preoperative SVA (p<0.001), last follow-up SVA (p<0.001), preoperative LL (p=0.001), last follow-up LL (p<0.001), subsequent L5–S1 disc degeneration (p<0.001) and PI (p=0.028). Patient age >61.5 years (OR=1.251, 95% CI, 1.055–1.484) (P=0.010), preoperative SVA >3.54 cm (OR=1.844, 95% CI, 1.249–2.732) (P=0.002) and preoperative LL <19.0 degrees (OR=0.922, 95% CI, 0.869–0.979) (P=0.008) were identified as predictors of deterioration in sagittal balance.

Conclusions

Deterioration in sagittal balance following long fusion arthrodesis to L5 in patients with adult scoliosis was associated with subsequent L5–S1 disc degeneration and loss of LL, age >61.5 years, preoperative SVA >3.54 cm, and preoperative LL <19.0 degrees.

The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications

BACKGROUND CONTEXT

In 2008, Mirza et al. designed and validated the first and only index capable of quantifying the complexity of spine surgery. However, this index is not fully applicable to adult spinal deformity (ASD) surgery as it does not include the surgical techniques most commonly used and most strongly associated with perioperative complications in patients with ASD.

PURPOSE

The objective of this study is to develop an "Adult Deformity Surgery Complexity Index" (ADSCI) to quantify objectively the complexity of the ASD posterior surgery.

STUDY DESIGN/SETTING

This is an expert consensus (Delphi process) and retrospective analysis of prospectively collected data using multiple regression models.

PATIENT SAMPLE

Patients were prospectively enrolled in two comparable multicenter ASD databases sharing the same inclusion criteria.

OUTCOME MEASURES

The ADSCI was internally and externally validated using R² for intraoperative bleeding and length of surgery. Receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to assess the sensitivity and specificity of ADSCI.

METHODS

The development and validation of ADSCI was based on the construction and comparison of three different tools: ADSCI score was constructed by three rounds of expert consensus (ADSCI-Delphi) and two multiple regression models (ADSCI-RM-Simple and ADSCI-RM-Mixed). Their predictive capability was compared by means of R² values in the same subrogated of surgical complexity as in the Mirza index validation: intraoperative bleeding and duration of surgery. Sensitivity and specificity were evaluated using ROC curves and AUC analysis. The external validity was also examined by evaluating its predictive capability in another multicenter ASD database of comparable patients in the United States.

RESULTS

At the time of the study, the database included 1,325 patients. Four hundred seventy-five patients were eligible for the study, having been treated surgically using a posterior approach only (52.2 years standard deviation 20; 77.7% women; 85.4% American Society of Anesthesiologists I/II). Fifty-one international experts participated in the Delphi consensus process. The surgical variables selected by consensus and included in the equation were divided into actions and factors. Actions selected were number of fused segments, decompressions, interbody fusions, and cemented levels; number and type of posterior osteotomies; and use of pelvic fixation. The factors included were implant density, revision surgery, and team experience. ADSCI-RM-Mixed (regression model with Delphi formula interactions) provided the best estimates and predictive value, well above Mirza's invasiveness index. The ADSCI-RM-Mixed, with greater AUCs (>0.70), was also the most sensitive and specific for both of the dependent variables studied and for complication prediction. ADSCI-RM-Mixed obtained also the highest R² value in the validation cohort in predicting blood loss (R²=0.34) and surgical time (R²=0.26) with effect sizes similar to those for the derivation cohort.

CONCLUSIONS

The ADSCI is the first tool to be specifically developed for the preoperative assessment of the complexity of ASD surgery. This study confirms its validity, specificity, and sensitivity, and shows that it has greater predictive capability than the more generic Mirza invasiveness index. The ADSCI should be useful for quantitatively estimating the increased risk associated with more invasive surgery and adjusting for surgical case-mix when making safety comparisons in ASDS.

Short Limited Fusion Versus Long Fusion With Deformity Correction for Spinal Stenosis With Balanced De Novo Degenerative Lumbar Scoliosis: A Meta-analysis of Direct Comparative Studies

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to identify advantages and disadvantages of long versus short fusion for patients with Spinal stenosis with Balanced de novo degenerative lumbar Scoliosis without substantial Sagittal imbalance (SBSS), and to determine whether short fusions and long fusions have different curve progression after surgeries and differences in operative characteristics.

SUMMARY OF BACKGROUND DATA

Patients with SBSS usually undergo short limited fusion or long fusion with curve correction. There is debate regarding whether short fusion is insufficient for SBSS for prevention scoliosis progression.

METHODS

A systematic search of PubMed, Embase, Web of Science, and the Cochrane Library was performed to find studies assessing the comparison of surgical techniques for SBSS. We included all direct comparative studies comparing short and long fusion and extracted data about scoliosis progression, changes in the Oswestry Disability Index (ODI), perioperative outcomes, and complication rates. A meta-analysis was performed to calculate weighted mean differences (WMDs) and 95% confidence intervals (CIs).

RESULTS

We included data from six studies involving 362 patients (short fusion, 202 patients; long fusion, 160 patients). Both the short fusion and the long fusion groups showed decreased Cobb angle (short, 22.38°-11.69°; long, 30.74°-12.77°) and C7 plumb at the final follow-up. The long fusion group showed a substantial decrease in Cobb angle (WMD, 8.94; 95% CI, 2.55-15.33) and in C7 plumb (WMD, 5.90; 95% CI, -0.39-12.18), compared to the short fusion group. At final follow-up, ODI had decreased similarly in both groups (WMD, 1.70; 95% CI, -13.04-9.65). The short fusion group showed advantages including decreased blood loss (mean difference, 739.9 mL) and shorter operative time (mean difference, 68.0 minutes) compared to the long fusion group.

CONCLUSION

Short fusion may be a reasonable option for patients with SBSS and at low risk for curve progression.

LEVEL OF EVIDENCE

1.

Utility of intraoperative rotational thromboelastometry in thoracolumbar deformity surgery

OBJECTIVE Blood loss during surgery for thoracolumbar scoliosis often requires blood product transfusion. Rotational thromboelastometry (ROTEM) has enabled the more targeted treatment of coagulopathy, but its use in deformity surgery has received limited study. The authors investigated whether the use of ROTEM reduces transfusion requirements in this case-control study of thoracolumbar deformity surgery. METHODS Data were prospectively collected on all patients who received ROTEM-guided blood product management during long-segment (≥ 7 levels) posterior thoracolumbar fusion procedures at a single institution from April 2015 to February 2016. Patients were matched with a group of historical controls who did not receive ROTEM-guided therapy according to age, fusion segments, number of osteotomies, and number of interbody fusion levels. Demographic, intraoperative, and postoperative transfusion requirements were collected on all patients. Univariate analysis of ROTEM status and multiple linear regression analysis of the factors associated with total in-hospital transfusion volume were performed, with p < 0.05 considered to indicate statistical significance. RESULTS Fifteen patients who received ROTEM-guided therapy were identified and matched with 15 non-ROTEM controls. The mean number of fusion levels was 11 among all patients, with no significant differences between groups in terms of fusion levels, osteotomy levels, interbody fusion levels, or other demographic factors. Patients in the non-ROTEM group required significantly more total blood products during their hospitalization than patients in the ROTEM group (8.5 ± 4.2 units vs 3.71 ± 2.8 units; p = 0.001). Multiple linear regression analysis showed that the use of ROTEM (p = 0.016) and a lower number of fused levels (p = 0.022) were associated with lower in-hospital transfusion volumes. CONCLUSIONS ROTEM use during thoracolumbar deformity correction is associated with lower transfusion requirements. Further investigation will better define the role of ROTEM in transfusion during deformity surgery.

The Case for Deformity Correction in the Management of Radiculopathy with Concurrent Spinal Deformity

The management of adult deformity varies significantly. Options range from nonoperative care to limited decompression to decompression with limited or extensive fusion. The appropriate surgical management is the approach that optimizes the likelihood of improvement in health-related quality of life, while limiting risks of complications and costs. Decompression alone is unreliable in the setting of significant deformity contributing to radiculopathy. Decompression with limited fusion is most appropriate for patients with age-appropriate global alignment of the spine, and decompression with more extensive fusion is most appropriate for patients with progressive deformity or with global sagittal or coronal malalignment.

Measuring outcomes in adult spinal deformity surgery: a systematic review to identify current strengths, weaknesses and gaps in patient-reported outcome measures

PURPOSE

Adult spinal deformity (ASD) causes severe disability, reduces overall quality of life, and results in a substantial societal burden of disease. As healthcare is becoming more value based, and to facilitate global benchmarking, it is critical to identify and standardize patient-reported outcome measures (PROMs). This study aims to identify the current strengths, weaknesses, and gaps in PROMs used for ASD.

METHODS

Studies were included following a systematic search in multiple bibliographic databases between 2000 and 2015. PROMs were extracted and linked to the outcome domains of WHO's International Classification of Functioning and Health (ICF) framework. Subsequently, the clinimetric quality of identified PROMs was evaluated.

RESULTS

The literature search identified 144 papers that met the inclusion criteria, and nine frequently used PROMs were identified. These covered 29 ICF outcome domains, which could be grouped into three of the four main ICF chapters: body function (n = 7), activity and participation (n = 19), environmental factors (n = 3), and body structure (n = 0). A low quantity (n = 3) of papers was identified that studied the clinimetric quality of PROMs. The Scoliosis Research Society (SRS)-22 has the highest level of clinimetric quality for ASD.

CONCLUSIONS

Outcome domains related to mobility and pain were well represented. We identified a gap in current outcome measures regarding neurological and pulmonary function. In addition, no outcome domains were measured in the ICF chapter body structure. These results will serve as a foundation for the process of seeking international consensus on a standard set of outcome domains, accompanied PROMs and contributing factors to be used in future clinical trials and spine registries.

Patient Satisfaction After Adult Spinal Deformity Surgery Does Not Strongly Correlate With Health-Related Quality of Life Scores, Radiographic Parameters, or Occurrence of Complications

STUDY DESIGN

This is a multicenter retrospective review of prospectively collected cases.

OBJECTIVE

Our objective was to evaluate the relationship between patient satisfaction, health-related quality of life (HRQoL) scores, complications, and radiographic measures at 2 years postoperative follow-up.

SUMMARY OF BACKGROUND DATA

For patients receiving operative management for adult spine deformity (ASD), the relationship between HRQoL measures, radiographic parameters, postoperative complications, and self-reported satisfaction remains unclear.

METHODS

Data from 248 patients across 11 centers within the United States who underwent thoracolumbar fusion for ASD and had a minimum of 2 years follow-up was collected. Pre- and postoperative scores were obtained from the Scoliosis Research Society 22-item (SRS-22r), the Oswestry Disability Index (ODI), the 36-Item Short Form Health Survey (SF-36), and the Visual Analogue Scale. Sagittal vertical axis, coronal C7 plumbline, lumbar lordosis, pelvic tilt, T1 pelvic angle, and the difference between pelvic incidence and lumbar lordosis were assessed using postoperative radiographic films. Satisfaction (SAT) was assessed using the SRS-22r; patients were categorized as highly satisfied (HS) or less satisfied (LS). The correlation between SAT and HRQoL scores, radiographic parameters, and complications was determined.

RESULTS

When compared with LS (n = 60) patients, HS (n = 188) patients demonstrated greater improvement in final ODI, SF-36 component scores, SRS-Total, and Visual Analogue Scale back scores (P < 0.05). The correlations between SAT and the final follow-up and 2 year change from baseline values were moderate for Mental Component Summary, Physical Component Summary, and ODI or weak for HRQoL scores (P < 0.0001). The HS and LS groups were equal in pre- or final postoperative radiographic parameters. Occurrence of complications had no effect on satisfaction.

CONCLUSION

Among operatively treated ASD patients, satisfaction was moderately correlated with some HRQoL measures, and not with radiographic changes or postoperative complications. Other factors, such as patient expectations and relationship with the surgeon, may be stronger drivers of patient satisfaction.

LEVEL OF EVIDENCE

3.

Clinical and radiological outcomes after decompression and posterior fusion in patients with degenerative scoliosis

OBJECTIVE

The prevalence of degenerative scoliosis (DS) increases with age and an overall increase is seen due to the aging population. This study aims to evaluate the clinical and radiological outcomes after decompression and posterior fusion in patients with DS.

METHODS

In this is prospective study, 43 patients with DS, aged 37 to 70 years, were eligible to undergo decompression and posterior fusion. Primary outcomes were low back pain (LBP) with or without radicular pain, which was evaluated preoperatively and at 12 and 24 months after surgery with the use of a visual analog scale (VAS), and the quality of life (QOL), which was assessed at the same time periods by the Oswestry Disability Index (ODI) questionnaire. The Cobb's method was used to measure the degree of scoliosis in each patient preoperatively and at 24 hours, 12 and 24 months after the surgery.

RESULTS

VAS scores improved significantly from a mean of 8.18 preoperatively to 4.48 at 12 months and 3.07 at 24 months postoperatively (P < .001). The mean radicular pain scores also decreased significantly (P < .001). At postoperative 12 months, the mean ODI score was significantly lower than the mean preoperative ODI score (47.81 ± 16.06 vs. 72.18 ± 12.28; P = .001). ODI score at 24 months postoperatively was significantly better than the preoperative ODI (15.53 ± 7.21 vs. 72.18 ± 12.28; P = .016). The mean Cobb angle changed significantly from 31.4° ± 4.88 preoperatively to 3.28° ± 2.10 at 24 months postoperatively (P < .001).

CONCLUSIONS

Our findings suggest that decompression and posterior fusion in the patients with DS is an effective surgical method which is associated with satisfying clinical results in terms of improvement of postoperative LBP, radicular pain, and QOL, and correction of Cobb angle at 12 and 24 months after the surgery and restoration of sagittal alignment at 2 months postoperatively.

Lumbar Radiculopathy in the Setting of Degenerative Scoliosis: MIS Decompression and Limited Correction are Better Options

Surgery for adult spinal deformity (ASD) has emerged as an efficient treatment alternative, but it is fraught with potential perioperative morbidity, incompletely mitigated by emerging minimally invasive surgical techniques. In mild-to-moderate ASD balanced in the sagittal plane, there are situations in which the counterintuitive simple decompression through a foraminotomy or laminectomy, or even a short-segment fusion may be an attractive treatment. This article presents a case example and the authors' treatment rationale and reviews the limited available literature supporting it.

[The effect of spinal deformity correction on the quality of life of elderly patients]

AIM

At present, there is no consensus on the approach to treatment of patients older than 60 years of age who have spinal deformity and clinical symptoms. The article describes the effect of two different types of surgery on the quality of life of elderly patients with deformities.

MATERIAL AND METHODS

A prospective study included 58 patients operated on at the Verden Russian Research Institute of Traumatology and Orthopedics in the period between 2007 and 2010. The inclusion criteria were as follows: patients older than 60 years of age, having spinal deformity (sagittal modifiers of grade 2(+) and higher according to the SRS-Schwab classification), radicular syndromes, and back pain. The patients were examined in accordance with a general algorithm, including general clinical and neurological examinations and an X-ray examination with evaluation of deformity, spinopelvic relationships, and sagittal imbalance. We compared two groups of patients. The first group included 28 patients who underwent decompressive foraminotomy. The second group consisted of 30 patients who underwent decompressive foraminotomy and deformity correction. The patients were evaluated using the following scales: VAS, ODI, and SRS-24 before surgery and after 3, 6 months, 1, 2, and 5 years.

RESULTS

Preoperatively, there was no difference between the groups. We found no differences between the groups 1 year after surgery. After 5 years, the group with isolated decompression had poorer results.

CONCLUSION

Spinal deformity correction is a more aggressive surgical procedure compared to isolated decompression. However, the efficacy of the former operation is higher.

Long vs. short fusions for adult lumbar degenerative scoliosis: does balance matters?

PURPOSE

Surgery of adult scoliosis was based upon coronal plane radiographical analysis using Cobb angle measurements, but recently it has been demonstrated that sagittal spinopelvic alignment plays a critical role in determining the final outcome. The aim of this paper is to compare the clinical and radiological results of 81 patients affected by adult scoliosis, treated with short or long fusions, and followed for 2-5 year follow-up.

MATERIALS AND METHODS

81 patients affected by degenerative lumbar scoliosis managed by posterior-only surgery were retrospectively evaluated. Fifty-seven patients underwent to a short fusion procedure, while 24 had a long fusion. Clinical and radiographic coronal and sagittal spinopelvic parameters were compared between the two groups.

RESULTS

Coronal Cobb angle was 24° preoperatively and passed to 12° in the short fusion group, while changed from 45° to 10° in the long fusion group. Lumbar lordosis was 45° preoperatively and 60° at final follow-up in the short fusion group passed from 24° to 55° in the long fusion group. Sacral slope passed from 25° to 45° in the short fusion group, while from 10° to 40° in the long fusion group. Pelvic tilt passed from 24° to 13° in the short fusion group, and from 28° to 23° in the long fusion group.

CONCLUSION

Surgical treatment of degenerative lumbar scoliosis improved balance and alignment of the spine, and also the coronal plane in terms of Cobb angle. These results were associated to a consistent clinical improvement and an acceptable rate of complications.