Sequential correction technique in degenerative scoliosis with type C coronal imbalance: a comparison with traditional 2-rod technique

OBJECTIVE The aim of this study was to compare the radiographic and clinical outcomes in patients with degenerative scoliosis (DS) with type C coronal imbalance who underwent either a sequential correction technique or a traditional 2-rod technique with a minimum of 2 years of follow-up. METHODS DS patients with type C coronal imbalance undergoing posterior correction surgery from February 2014 to January 2018 were divided into groups by technique: the sequential correction technique (SC group) and the traditional 2-rod technique (TT group). Radiographic parameters, including Cobb angle, coronal balance distance (CBD), global kyphosis (GK), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope, were assessed pre- and postoperatively. The SF-36 questionnaire was used to assess quality of life. RESULTS A total of 34 patients were included. Significant postoperative improvement in the Cobb angle of the main curve, CBD, GK, TK, LL, SVA, and PT was found in both groups (p < 0.05). Postoperatively, the coronal balance was type A in 13 patients (92.9%) in the SC group and in 16 patients (80.0%) in the TT group (p = 0.298). In the TT group, 1 patient had deteriorative coronal imbalance immediately postoperatively, and coronal imbalance deteriorated from type A to type C in 2 patients during follow-up. The scores of Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health were statistically improved postoperatively (p < 0.05) in both groups. Type C coronal imbalance at the last follow-up was associated with a relatively worse quality of life. There were no implant failures during follow-up in the SC group, whereas rod fracture was observed in 3 patients in the TT group. CONCLUSIONS Compared with the traditional 2-rod technique, the sequential correction technique can simplify rod installation procedure, enhance internal instrumentation, and reduce risk of implant failures. The sequential correction technique could be routinely recommended for DS patients with type C coronal imbalance.

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.

Kinesiophobia and its association with treatment choice in individuals with idiopathic scoliosis

BACKGROUND: Previous studies have reported increased kinesiophobia in adults with degenerative scoliosis or adolescents who have undergone spinal surgery. However, little is known about the phenomenon of kinesiophobia among adolescents with idiopathic scoliosis (IS). OBJECTIVES: The aim of this study was to investigate levels of kinesiophobia and its association with treatment choice in IS. METHODS: The study included 98 IS patients with a mean age of 14 years and 20 healthy controls. Participants with IS were divided into groups based on treatment conditions, as follows: (1) untreated (n= 33); (2) treated with exercise (n= 32); and (3) treated with a brace (n= 33). Kinesiophobia was measured using the Tampa Scale for Kinesiophobia (TSK). Comparisons were made between four groups. RESULTS: Untreated participants with IS were found to have greater kinesiophobia than healthy controls (p< 0.001). Participants treated with a brace (p= 0.046) and exercise (p= 0.064) had similar kinesiophobia levels as the healthy control group. CONCLUSIONS: Kinesiophobia was found to be higher in adolescents with IS compared to healthy peers. Brace or exercise treatment both had a positive impact on kinesiophobia. These findings should be considered when organizing rehabilitation programs to achieve the best results for adolescents with IS.

Which sagittal evaluation system can effectively predict mechanical complications in the treatment of elderly patients with adult degenerative scoliosis? Roussouly classification or Global Alignment and Proportion (GAP) Score

Background To achieve the proper sagittal alignment, previous studies have developed different assessment systems for adult degenerative scoliosis (ADS) which could help the spine surgeon in making treatment strategies. The purpose of our study is to evaluate whether Roussouly classification or global alignment and proportion (GAP) score is more appropriate in the prediction of mechanical complications after surgical treatment of ADS. Methods ADS patients who received long segmental fusion in the treatment during the period from December 2016 to December 2018 were evaluated in this study. Basic information and radiologic measurements were collected for analysis. Patients were divided into two groups according to occurrence or absence of mechanical complications for comparison. Mechanical complications included proximal junctional kyphosis (PJK), proximal junctional failure (PJF). GAP categories divided GAP score into proportioned spinopelvic position, moderately disproportioned position, and severely disproportioned position according to the cut-off values. The correlation between evaluation systems and mechanical complications was analyzed through a logistic regression model via stepwise backward elimination based on the Wald statistics. Receiver operator characteristic (ROC) curve was used to determine the predictability of the evaluation systems in the occurrence of mechanical complications and calculate their cut-off value. Area under the curve (AUC) was used to evaluate the validity of the thresholds. Results A total of 80 patients were included in this study. There were 41 patients in mechanical complication group and 39 patients in no mechanical complication group. GAP score (P = 0.008) and GAP categories (P = 0.007) were positively correlated with mechanical complications; Roussouly score was negatively correlated with mechanical complications (P = 0.034); GAP score was positively correlated with PJK (P = 0.021); Roussouly score was negatively correlated with implant-related complications (P = 0.018); GAP categories were correlated with implant loosening (P = 0.023). Results of ROC showed that GAP score was more effective in predicting PJK (AUC = 0.863) and PJF (AUC = 0.724) than Roussouly score; GAP categories (AUC = 0.561) was more effective than GAP score (AUC = 0.555) in predicting implant-related complications. Conclusions Roussouly classification could only be a rough estimate of optimal spinopelvic alignment. Quantitative parameters in GAP score made it more effective in predicting mechanical complications, PJK and PJF than Roussouly classification.

Robotic Sacroiliac Fixation Technique for Triangular Titanium Implant in Adult Degenerative Scoliosis Surgery: 2-Dimensional Operative Video

Corrective surgery remains a definitive treatment for adult spinal deformity, improving pain and disability. With these cases, instrumentation to the pelvis with iliac fixation is recommended. Whether iliac or S2-Alar-Iliac (S2AI) trajectories are used, sacroiliac joint pain and long-term sacroilitis can be common after long-fusion constructs.1-3 Sacroiliac fusion with triangular titanium implants during fusion can reduce back pain associated with sacroiliac joint degeneration,3 provides reduction in sacroiliac joint motion and stress when added to S2AI screws, and potentially enhances mechanical stability of fusion constructs.4 Here, we present a technique for placing triangular titanium sacroiliac implants (iFuse BedrockTM; SI-BONE Inc, Santa Clara, California) alongside S2AI screws using a robotic platform (Mazor X; Medtronic Sofamor Danek, Medtronic Inc, Dublin, Ireland). Navigated robotics allows reduction in human error with implant placement, and potentially decreased operative time/fluoroscopy.5-7 Key surgical steps include placement of K wires for S2AI and bilateral SI-implants, tapping, replacing SI-implant K wires with guide pins, placing S2AI screws, and finally placing the SI-implant. Final placement is verified with intraoperative fluoroscopy. The patient described is a 61-yr-old woman with worsening adult degenerative scoliosis, lower back pain, left leg radicular pain, and mild right leg pain who failed conservative treatment. Examination revealed diminished strength in both legs. Imaging was significant for moderate sigmoid scoliosis, discogenic disease, and osteoarthritis at all levels. She consented to undergo corrective surgery. Postoperatively, the patient experienced resolution of her leg weakness and pain. Imaging demonstrated appropriate positioning of hardware. Prospective studies on the efficacy of the SI-implant are underway.

Analysis of Clinical Effect of Interbody Fusion and Internal Fixation on Degenerative Scoliosis

In this study, we analyzed the clinical effect of interbody fusion and internal fixation on degenerative scoliosis. Methods: After degenerative lumbar scoliosis (DLS) surgery, patients were retrospectively evaluated using VAS (Visual Analogue Scale) and ODI (Oswestry Disability Index) to evaluate clinical efficacy. All patients underwent posterior lumbar decompression laminectomy, pedicle screw internal fixation and posterolateral bone graft fusion.Imaging measurements include scoliosis Cobb angle, fusion Cobb angle, intervertebral angle (AIA), sagittal intervertebral angle (SIA), and lumbar lordosis angle. The relationship between these parameters was tested by binary Pearson analysis and linear regression analysis. Results: Before surgery, the Cobb angle of the scoliosis segment was 15.3°, and it dropped to 10.1° immediately after the operation (P <0.05). Compared with preoperative and postoperative values (2.4°2.7 and 2.1 °2.3, respectively; P <0.05), AIA increased significantly (4.3°3.3) at the last follow-up. However, scoliosis Cobb angle and AIA were not related to VAS or ODI scores. At the final follow-up, no patients developed pseudoarthritis or internal device-related complications. Conclusion: Intervertebral bone fusion and internal fixation resulted in limited DLS correction, and the correction effect decreased over time. The AIA between the upper adjacent segment and the proximal fusion vertebrae continues to increase after surgery, but it does not worsen the clinical symptoms, which is reflected in the lower reoperation rate of the adjacent level of repair recurrence rate.