Correlation between radiographic parameters and functional scores in degenerative lumbar and thoracolumbar scoliosis

Does the Extent of Rod Bending and Actual Lumbar Lordosis Mismatch Affect Quality of Life?

BACKGROUND

To evaluate any mismatch between rod bending and actual lordosis during posterior lumbar instrumentation and its effects on the quality of life (QOL) of patients.

METHODS

Patient records for posterior lumbar fusion in 2018-2023 were retrospectively reviewed. The radiologic parameters consisted of pelvic incidence, sacral slope, L1S1 lumbar lordosis, lumbosacral angle, the distance between the posterior wall of the vertebra and the rod, lordosis of the rod. The postoperative QOL of patients was assessed using Oswestry Disability Index. The patients were grouped postoperative into Group-1 (minimal/moderate disability) and Group-2 (severe disability/crippled/bed bound).

RESULTS

Total of 133 patients were included; 99 women, 34 men. The difference was significant for patients with diabetes to be presented in the more disabled Group-2. The distance between the posterior vertebral wall and the rod was found to be short in Group-2. Preoperative and postoperative sagittal lumbar Cobb angles were significantly higher in Group-2. The changing degree of pain was found to score high in Group-2. The postoperative visual analog scale was high in Group-2. The difference between the preoperative and postoperative lumbar sagittal Cobb and rod Cobb-angles was found to be high in Group-2.

CONCLUSIONS

The results of our study confirm the importance of considering the preoperative actual lumbar lordosis during bending and maintaining it as much as possible. To our knowledge, this is the first study that evaluated the effect of rod bending on quality of life (QOL) and supports that this might be affected in case of any mismatches.

Isokinetic strength assessment of trunk muscle and its relationship with spinal-pelvic parameters in patients with degenerative spinal deformity

BACKGROUND

The incidence rate of degenerative spinal deformity (DSD) has gradually increased in the elderly. Currently, the relationship between the functional status of trunk muscle and the spinal-pelvic parameters of DSD patients remains unclear.

OBJECTIVE

This paper aims to explore the relationship between the two factors and provide new clues for exploring the mechanism of the occurrence and development of DSD.

METHODS

A total of 41 DSD patients treated in our hospital (DSD group) and 35 healthy volunteers (control group) were selected. Muscle strength was evaluated using an IsoMed-2000 isokinetic dynamometer, and the trunk flexor and extensor peak torque (PT) of subjects was measured at a low, medium, and high angular velocity of 30∘/s, 60∘/s, and 120∘/s, respectively. Hand grip strength (HGS) was assessed using an electronic grip dynamometer and Surgimap software was used to measure the spinal-pelvic parameters, including the sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence rate (PI), and PI-LL, and the relationship between trunk muscle function and various parameters was analyzed.

RESULTS

Under the three angular velocities, the flexor and extensor PT values in the DSD group were lower than those in the control group, and only the extensor PT showed a statistically significant difference (P< 0.05). There was no significant difference in HGS between the two groups (P> 0.05). In the DSD group, the extensor PT at 30∘/s was significantly negatively correlated with SVA (P< 0.05). At 60∘/s and 120∘/s, the extensor PT was significantly negatively correlated with SVA and PT (P< 0.05).

CONCLUSION

Trunk extensor strength is significantly lower in DSD patients than in normal controls. The decline in trunk extensor strength in DSD patients is a type of local muscle dysfunction more closely related to the deformity, which is likely involved in the compensatory mechanism of DSD and may reflect the overall imbalance of the trunk.

Recovery ratios and minimum clinically important difference for clinical outcomes in workers' compensation recipients undergoing MIS-TLIF versus ALIF

BACKGROUND

There is a scarcity of literature that examines clinical outcomes through patient-reported outcomes (PROs), minimum clinically important difference (MCID), and recovery ratios (RR) for workers' compensation (WC) recipients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) versus anterior lumbar interbody fusion (ALIF).

METHODS

WC claimants undergoing MIS-TLIF versus ALIF were propensity score matched to account for demographic differences. Demographics, perioperative characteristics, and PROs were collected. PROs of Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form Physical Composite Score (SF-12 PCS), Visual Analog Scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative time points. MCID achievement was determined through comparison to values in literature. RR was calculated as the difference between postoperative and preoperative PROs over potential improvement. Comparison between surgical techniques was through non-parametric inferential statistics.

RESULTS

Eighty-four WC claimants, with 50 patients undergoing MIS-TLIF, were identified after propensity score matching. ALIF patients had higher estimated blood loss. MIS-TLIF patients had higher postoperative day (POD) 0 VAS pain and POD 0 + 1 narcotic consumption. Patients undergoing either MIS-TLIF or ALIF reported significant improvement in pain and disability. ALIF patients reported significant improvement in physical function. ALIF patients reported superior 1-year PROMIS-PF, 6-week SF-12 PCS, 6-month VAS back, and 12-week VAS leg. No significant differences in MCID achievement rates were noted between cohorts. ALIF patients had higher RR in 6-week and 1-year PROMIS-PF and 6-week SF-12 PCS.

CONCLUSION

Workers' compensation claimants undergoing either MIS-TLIF or ALIF reported significant improvement in pain and disability. ALIF patients reported superior postoperative physical function and pain. ALIF patients had higher recovery ratios in physical function. Workers' compensation claimants undergoing ALIF may experience greater physical function recovery and superior clinical outcomes in physical function and pain.

Correlation Analysis of the Characteristics of Spino-Pelvic Parameters and Health-Related Quality of Life After Long-Segment Fixation for Lenke–Silva Type 5 or 6 Degenerative Scoliosis

Purpose

To retrospectively evaluate the characteristics of spino-pelvic parameters after long-segment fixation in patients with Lenke–Silva type 5 or 6 adult degenerative scoliosis and analyze the correlation between spino-pelvic parameters and health-related quality of life (HRQL).

Methods

Thirty-two patients with degenerative scoliosis underwent long-segment posterior fixation were included. The spino-pelvic parameters were evaluated after surgery, and the HRQL scores were determined using the Scoliosis Research Society-22 (SRS-22), Oswestry Disability Index (ODI), and visual analog scale (VAS). Linear regression was used to analyze the correlation between changes in spino-pelvic parameters and improvements in HRQL.

Results

Except for PI and TK, the other parameters showed significant differences after surgery (P < 0.05). All the scores of HRQL showed significant differences after surgery. The coefficient of correlation between ΔSVA and ΔVAS is 0.687 (P = 0.003), the coefficient of correlation between ΔSVA and ΔODI is 5.828 (P < 0.001). The coefficient of correlation between ΔLL and ΔVAS is −0.089 (P < 0.001), the coefficient of correlation between ΔLL and ΔODI is −1.553 (P = 0.003). The VAS score between the SVA ≥ 4cm and SVA < 4cm group have no significant difference, but have a significant difference in ODI. In PI-LL ≥ 20°and PI-LL < 20°group, the VAS and ODI all have a significant difference between the two groups.

Conclusion

SVA and LL have an important role in maintaining the overall balance of the spine and closely related to the postoperative HRQL, better HRQL may be achieved by reducing SVA and increasing LL. Good preoperative design will help achieve the best clinical efficacy.

Optimal Correction of Adult Spinal Deformities Requires Restoration of Distal Lumbar Lordosis

PURPOSE

The aim of this study is to analyze results according to postoperative pelvic incidence-lumbar lordosis (PI-LL) mismatch in the management of adult spine deformity (ASD) patients. Recently, it has been reported that in addition to lumbar lordosis amount, lordosis repartition between its proximal and distal parts was crucial.

METHODS

We enrolled 77 consecutive ASD patients who underwent posterior spinal fusion and deformity correction between 2015 and 2018. On preoperative and 1-year follow-up radiographs, we analyzed different parameters such as L1-S1 lumbar lordosis, L1-L4 proximal lordosis (PLL), L4-S1 distal lordosis (DLL), pelvic tilt (PT), sagittal vertical axis (SVA), and PI-LL mismatch. Comparisons were performed according to postoperative PI-LL mismatch (defined as "aligned" when PI-LL was <10°). The relationship between lordosis distribution and postoperative alignment status was investigated.

RESULTS

On the whole series, average lumbar lordosis, SVA, and PI-LL improved (28.2° vs.43.5°, 82 vs. 51 mm, and 26°vs. 14°, all p < 0.001, respectively). On the other hand, PT remained unchanged (30° vs. 28°, p > 0.05). 35 patients were classified as "aligned" and 42 as "not aligned." Patients from the "aligned" group had a significantly lower PI than patients from the "not aligned" group (52° vs. 61°, p=0.009). Postoperative PLL was not different between groups (18° vs. 16° p > 0.05), whereas DLL was significantly higher in the "aligned" group (31° vs. 22°, p=0.003). PI-LL was significantly correlated to DLL (rho = 0.407, p < 0.001) but not with PLL (rho = 0.110, p=0.342).

CONCLUSIONS

Our results revealed that in ASD patients, postoperative malalignment was associated with a lack of DLL restoration. "Not aligned" patients had also a significantly higher pelvic incidence. Specific attention must be paid to restore optimal distal lumbar lordosis in order to set the amount and the distribution of optimal postoperative lumbar lordosis.

Prospective investigation of Oswestry Disability Index and short form 36 subscale scores related to sagittal and coronal parameters in patients with degenerative lumbar scoliosis

PURPOSE

This study investigated relationships of Oswestry Disability Index (ODI) and Short Form 36 (SF-36) total and subscale scores with global spinal parameters in patients with degenerative lumbar scoliosis (DLS).

METHODS

This was a prospective single-center study of 126 consecutive patients with DLS. Disability was evaluated using the ODI and SF-36 total and subscale scores. Sagittal and coronal parameters were measured. Pearson's correlation analysis was performed to determine relationships between disability and radiographic parameters.

RESULTS

The study population included 76 women and 15 men (mean age, 70.2 ± 8.4 years). Mean Cobb angle was 18.9° ± 8.0°. The ODI total score and SF-36 physical component score were only correlated with coronal parameters. ODI pain intensity, personal care, lifting, sitting, and sex life domains were only correlated with coronal parameters. The walking, standing, social life, and traveling domain scores were correlated with coronal and sagittal parameters. The SF-36 bodily pain and vitality domain scores were only correlated with coronal parameters. The SF-36 physical function domain score was correlated with both coronal and sagittal parameters. Among the clinical and radiographic parameters, the personal care score and the coronal vertical-axis had the strongest correlation (r = 0.425), although the r² value was only 0.18.

CONCLUSIONS

ODI total score and most of the subscale scores were significantly, but weakly correlated with coronal parameters. Sagittal parameters were only correlated with some of the ODI and SF-36 subscale scores. Analysis using ODI and SF-36 subscale scores may aid in understanding and treatment of disability in patients with DLS.

Use of the sagittal Cobb* angle to guide the rod bending in the treatment of thoracolumbar fractures: a retrospective clinical study

Background

Pedicle screw fixation is a well-established technique for thoracolumbar fracture. A large number of studies have shown that the bending angle of the connecting rod has a significant correlation with the postoperative spinal stability. However, no studies have confirmed an objective indicator to guide the bending angle of the connecting rod during the operation. Our study aims to define a sagittal Cobb* angle to guide the bending angle of the connecting rod during surgery.

Methods

The frontal and lateral X-ray films in 150 cases of normal thoracolumbar spine were included to measure the normal spinal sagittal Cobb* angle in each segment. The patients who underwent single segment thoracolumbar fractures and pedicle screw internal fixation surgery were included. The radiological parameters included lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), and sacral slope (SS) were measured. The incidence of adjacent segment degeneration (ASD) 2 years after surgery was measured.

Results

The average values of normal sagittal Cobb* angle in each segment were − 5.196 ± 3.318° (T12), 2.279 ± 3.324° (L1), 7.222 ± 2.798° (L2), and 12.417 ± 11.962° (L3), respectively. The LL in the three groups was 35.20 ± 9.12°, 46.26 ± 9.68°, and 54.24 ± 15.31°, respectively. Compared with the normal group, there were significant differences in group A and group C, respectively (p < 0.05). The results were similar in the parameters of TL, PT, and SS. The incidences of SVA > 50 mm in group A, group B, and group C were 23.33%, 12.50%, and 19.23%, respectively. The parameter of PI in three groups was 41.36 ± 12.69, 44.53 ± 15.27, and 43.38 ± 9.85°, respectively. The incidences of ASD in group A, group B, and group C 2 years after surgery were 21.67%, 13.75%, and 17.95%, respectively.

Conclusions

The study confirmed that the sagittal Cobb* angle can be used as a reference angle for bending rods. When the bending angle of the connecting rod is 4 to 8° greater than the corresponding segment sagittal Cobb* angle, the patient’s spinal sagittal stability is the best 2 years after the operation.

LLIF IN THE CORRECTION OF DEGENERATIVE SCOLIOSIS IN ELDERLY PATIENTS

ABSTRACT Objective The incidence of adult degenerative scoliosis (ADS) among individuals over 50 years old can be as high as 68%. Surgical interventions aimed at correcting the spinal deformity in elderly patients are accompanied by a high risk of complications. The use of lateral lumbar interbody fusion (LLIF) is associated with lower rates of complications when compared with open anterior or posterior fusions. Methods Ninety-three patients with ADS (23 men, 70 women) were operated at the Federal Neurosurgical Center. The average age was 63 (52 to 73 years). Results Back pain, measured according to the Visual Analogue Scale (VAS), decreased from 5.9/6 (4;8) (format – mean/median (1;3 quartile)) to 2.6/3 (1;3) points (p <0.0001). Leg pain according to the VAS decreased from 4.6/4 (3;7) to 1.4/1 (0;2) points (p < 0.0001). Functional adaptation according to the Oswestry Disability Index (ODI) improved from 47.8±17.4 to 38.5±14.5 (p < 0.0273). Pelvic tilt (PT) before the surgery was 23.9±12.2° whereas at 12 months follow-up it was 16.8±5.9° (p < 0.0001). PI-LL mismatch pre surgery was 12.1/13 (9;16)° whereas 12 months later it was 7.9/8 (6;10)° (p = 0.0002). Conclusions Restoration of local sagittal balance in ADS patients by short-segment fixation using LLIF technology leads to a statistically significant improvement in quality of life and increased functional adaptation. A lower incidence of early and late postoperative complications, less intraoperative blood loss and shorter hospital stay makes LLIF, in combination with minimally invasive transpedicular fixation, the method of choice to correct ADS in elderly patients. Level of evidence IV; Case series.

Correlations between radiographic spinopelvic parameters and health-related quality of life: A prospective evaluation of 37 patients with facioscapulohumeral muscular dystrophy

OBJECTIVE

The purpose of this study was to evaluate the relationship between spinopelvic parameters and health-related quality of life.

METHODS

Patients with Facioscapulohumeral muscular dystrophy (FSHD) were asked to volunteer to participate in this study from April 2018 to December 2019. Patient data, including age, sex, body mass index (BMI), and duration of the diagnosis of FSHD were obtained. Short Form (SF-36) questionnaire was completed for all patients. All patients underwent lateral radiography of the whole spine. The radiographic parameters examined were pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), cervical lordosis (CL), T1 spinopelvic inclination (T1 SPI), thoracic kyphosis (TK), Pelvic incidence- lumbar lordosis (PI-LL) and sagittal vertical axis (SVA).

RESULTS

Thirty-seven patients (16 females and 21 males) were included in the study, with a mean age of 39.1 years. The mean duration of diagnosis was 13.5 ± 11.4 years and mean BMI was 24.2 kg/m2. Physical composite score (PCS) was 38.7 and mental composite score (MCS) 60.8 detected. Radiographic analyses included the following: the mean PT was 9.1°, PI 52.1°, SS 43.5°, LL 67.9°, CL 9.8°, T1 SPI -2.5°, TK 23.1°, SVA 37.6 mm. PI-LL was -13.1°. We identified 31 patients with match (left) PI-LL and six patients with mismatch (right) PI-LL.

CONCLUSION

Hyperlordosis inlumbar spine, hypolordosis in cervical spine and negative sagittal balance were the most common spinal misalignments in patients with FSHD. These patients have lower composite PCS than composite MCS. There was a significantly negative correlation between LL, PI-LL and PCS.

LEVEL OF EVIDENCE

Level IV Cross-sectional study.

Clinical Efficacy of Laminectomy with Instrumented Fixation in Treating Thoracolumbar Intradural Extramedullary Schwannomas: A Comparative Study

Background

This study investigated the clinical effect of laminectomy plus pedicle screw fixation in treating thoracolumbar intradural extramedullary schwannomas.

Material/Methods

Between October 2011 and May 2017, 57 patients undergoing resection of thoracolumbar schwannomas were retrospectively identified and included in the study. Based on the surgical procedures used, all participants were assigned to either the laminectomy-only group (n=33) or the combination group (laminectomy plus pedicle screw fixation, n=24). All participants were followed up for over 2 years. In the laminectomy, the spinal process, vertebral laminae, and bilateral upper articular processes of the surgical segments were completely resected and the lower articular processes were reserved. For further analysis, we evaluated the pain levels using visual analogue scale (VAS) score. The assessment of neurological function was performed with Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI). The comparisons of Cobb angle changes were carried out pre-surgery and post-surgery.

Results

The demographic data were well matched between the laminectomy-only group and combination group, without significant differences (P>0.05). After surgery, both surgical procedures achieved significant improvement in VAS score, ODI, and JOA score (P<0.001), but no significant differences were found between these 2 surgical procedures (P>0.05). The postoperative change in Cobb angle indicated a significant difference in the laminectomy-only group, but not in the combination group (P<0.05). In addition, postoperative spinal instability/deformity was found in the laminectomy-only group (P<0.05).

Conclusions

In conclusion, the combination of laminectomy and pedicle screw fixation is a safe and effective surgical procedure when used to treat thoracolumbar schwannoma, and appears to be superior to the laminectomy-only procedure.

Indirect foraminal decompression and improvement in the lumbar alignment after percutaneous cement discoplasty

PURPOSE

Percutaneous cement discoplasty (PCD) is a minimally invasive surgical procedure, that can provide a segmental stabilizing and indirect decompression effect in case of severely degenerated discs characterized by vacuum phenomenon. The objective of this study was to evaluate the effects of PCD on spinopelvic radiological parameters and their associations with the clinical outcome.

METHODS

Retrospective analysis of prospectively collected dataset of 28 patients (112 lumbar segments) who underwent single- or multilevel PCD was performed. Spinopelvic, intrasegmental and intersegmental parameters were measured on lumbar X-rays pre-, postoperatively and 6 months after the surgery. Correlations between radiological parameters and clinical outcome data were determined.

RESULTS

Sacral slope significantly increased (p < .001), and pelvic tilt (p < .05) was decreased after the PCD procedure. Segmental and total lordosis (p < .05, p < .05) disc and foraminal height showed significantly increase (p < .001, p < .001) after procedure. Pain and disability (ODI) significantly decreased due to PCD. An association was found between postoperative increase in SS and improvement in ODI (r = 0.39, p < .05). The change in low back pain was correlated with segmental scoliosis correction (p < .001). Moderate correlation was detected between the increase in disc height and ODI (p < .05) as well as leg pain (p < .01).

CONCLUSION

PCD is an effective minimally invasive technique to treat axial pain and disability related to severe lumbar disc degeneration. Our study shows that an improvement in lumbar alignment and a significant indirect foraminal decompression could be achieved with the procedure. These changes can significantly contribute to the pain relief and increase in the patients' functional capacity. These slides can be retrieved under Electronic Supplementary Material.

Evaluation of an increased strut porosity silicate-substituted calcium phosphate, SiCaP EP, as a synthetic bone graft substitute in spinal fusion surgery: a prospective, open-label study

Purpose

Silicate-substituted calcium phosphate-enhanced porosity (SiCaP EP, Inductigraft™, Altapore) is a synthetic bone graft material with enhanced strut porosity of 31–47%. SiCaP EP remains to be fully clinically evaluated in patients undergoing instrumented posterolateral fusion (PLF) surgery. We conducted a prospective, open-label, non-randomised, multicentre clinical study to evaluate efficacy of SiCaP EP as bone grafting material in PLF surgery with instrumentation for treatment of spinal disorders.

Methods

Patients with degenerative disc disease, spondylolisthesis or spinal stenosis underwent PLF surgery with SiCaP EP. The primary endpoint was evaluated in the per protocol population (N = 102) as solid fusion at postoperative month 12 assessed using computed tomography scans, with motion assessed using flexion–extension radiographs. Clinical outcomes included the Oswestry Disability Index, 36-item short-form health survey for quality-of-life, visual analog scale for pain scores and neurological assessments. Adverse events were recorded.

Results

Successful fusion was achieved in 59/89 (66.3%) patients at month 6, 88/102 patients (86.3%) at month 12 (primary endpoint) and 87/96 (90.6%) patients at month 24. Disability and pain reduced following surgery. Quality-of-life improved and neurological function was maintained postoperatively. Forty-three (33.3%) of the 129 patients who underwent surgery experienced adverse events; back pain was most frequent (n = 10); nine and 14 patients experienced serious adverse events judged related to device and procedure, respectively.

Conclusions

Enhanced strut porosity SiCaP EP provided high (month 12: 86.3%) spinal fusion success rates in PLF surgery. Fusion success was associated with improved clinical outcomes in patients within 12 months, relative to baseline.

ClinicalTrials.gov identifier

NCT01452022

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.