Surgical treatment of pathological loss of lumbar lordosis (flatback) in patients with normal sagittal vertical axis achieves similar clinical improvement as surgical treatment of elevated sagittal vertical axis

Object Increased sagittal vertical axis (SVA) correlates strongly with pain and disability for adults with spinal deformity. A subset of patients with sagittal spinopelvic malalignment (SSM) have flatback deformity (pelvic incidence–lumbar lordosis [PI-LL] mismatch > 10°) but remain sagittally compensated with normal SVA. Few data exist for SSM patients with flatback deformity and normal SVA. The authors' objective was to compare baseline disability and treatment outcomes for patients with compensated (SVA < 5 cm and PI-LL mismatch > 10°) and decompensated (SVA > 5 cm) SSM. Methods The study was a multicenter, prospective analysis of adults with spinal deformity who consecutively underwent surgical treatment for SSM. Inclusion criteria included age older than 18 years, presence of adult spinal deformity with SSM, plan for surgical treatment, and minimum 1-year follow-up data. Patients with SSM were divided into 2 groups: those with compensated SSM (SVA < 5 cm and PI-LL mismatch > 10°) and those with decompensated SSM (SVA ≥ 5 cm). Baseline and 1-year follow-up radiographic and health-related quality of life (HRQOL) outcomes included Oswestry Disability Index, Short Form–36 scores, and Scoliosis Research Society–22 scores. Percentages of patients achieving minimal clinically important difference (MCID) were also assessed. Results A total of 125 patients (27 compensated and 98 decompensated) met inclusion criteria. Compared with patients in the compensated group, patients in the decompensated group were older (62.9 vs 55.1 years; p = 0.004) and had less scoliosis (43° vs 54°; p = 0.002), greater SVA (12.0 cm vs 1.7 cm; p < 0.001), greater PI-LL mismatch (26° vs 20°; p = 0.013), and poorer HRQOL scores (Oswestry Disability Index, Short Form-36 physical component score, Scoliosis Research Society-22 total; p ≤ 0.016). Although these baseline HRQOL differences between the groups reached statistical significance, only the mean difference in Short Form–36 physical component score reached threshold for MCID. Compared with baseline assessment, at 1 year after surgery improvement was noted for patients in both groups for mean SVA (compensated –1.1 cm, decompensated +4.8 cm; p ≤ 0.009), mean PI-LL mismatch (compensated 6°, decompensated 5°; p < 0.001), and all HRQOL measures assessed (p ≤ 0.005). No significant differences were found between the compensated and decompensated groups in the magnitude of HRQOL score improvement or in the percentages of patients achieving MCID for each of the outcome measures assessed. Conclusions Decompensated SSM patients with elevated SVA experience significant disability; however, the amount of disability in compensated SSM patients with flatback deformity caused by PI-LL mismatch but normal SVA is underappreciated. Surgical correction of SSM demonstrated similar radiographic and HRQOL score improvements for patients in both groups. Evaluation of SSM should extend beyond measuring SVA. Among patients with concordant pain and disability, PI-LL mismatch must be evaluated for SSM patients and can be considered a primary indication for surgery.

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Scoliosis Research Society-Schwab Grade 6 Osteotomy for Severe Congenital Angular Kyphoscoliosis: An Analysis of 17 Cases With a Minimum 2-Year Follow-up

Neurosurgery ◽

10.1093/neuros/nyaa055 ◽

2020 ◽

Vol 87 (5) ◽

pp. 925-930 ◽

Cited By ~ 1

Author(s):

Bo Shi ◽

Benlong Shi ◽

Dun Liu ◽

Yang Li ◽

Sanqiang Xia ◽

...

Keyword(s):

Cobb Angle ◽

Clinical Outcomes ◽

Vertical Axis ◽

Research Society ◽

Sagittal Vertical Axis ◽

Vertebral Column Resection ◽

Scoliosis Research Society ◽

Rod Breakage ◽

The Mean

Abstract BACKGROUND For some patients with severe congenital angular kyphoscoliosis (SCAK), 1-level vertebral column resection is insufficient and the Scoliosis Research Society (SRS)-Schwab Grade 6 osteotomy may be necessary. However, the indications and clinical outcomes of SRS-Schwab Grade 6 osteotomy in patients with SCAK have not been investigated in depth. OBJECTIVE To investigate the middle-term radiographic and clinical outcomes, and to evaluate the safety of this high technique-demanding procedure. METHODS Patients with SCAK undergoing SRS-Schwab Grade 6 osteotomy from 2005 to 2016 followed up at least 2 yr were retrospectively reviewed. The potential indications of SRS-Schwab Grade 6 osteotomy were analyzed. The coronal Cobb angle, segmental kyphosis (SK), deformity angular ratio (DAR), coronal balance, and sagittal vertical axis (SVA) were measured in the preoperative, postoperative, and final follow-up. The intraoperative and postoperative complications were recorded. RESULTS A total of 17 patients with SCAK (10 M and 7F) were included, and the mean follow-up was 30.8 ± 16.4 mo. The indications of SRS-Schwab Grade 6 osteotomy were as follows: multiple “pushed-out” hemivertebrae (13, 76.5%) and multilevel anterior block (4, 23.5%). Compared with preoperation, the coronal Cobb angle, SK and SVA at postoperation were significantly improved (P < .05 for all). The mean total DAR was 33.4 ± 9.9 at preoperation. Three patients were found to have postoperative neurological deficit. Rod breakage occurred in 3 patients at 15- to 48-mo follow-up, and revision surgeries were performed. At the last follow-up, firm bony fusion was observed in all patients. CONCLUSION The technique-demanding SRS-Schwab Grade 6 osteotomy, if well indicated, could provide satisfying correction of the SCAK deformity.

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Recovery Kinetics of Radiographic and Implant-Related Revision Patients Following Adult Spinal Deformity Surgery

Neurosurgery ◽

10.1093/neuros/nyx490 ◽

2017 ◽

Vol 83 (4) ◽

pp. 700-708 ◽

Cited By ~ 1

Author(s):

Peter G Passias ◽

Cyrus M Jalai ◽

Virginie Lafage ◽

Gregory W Poorman ◽

Shaleen Vira ◽

...

Keyword(s):

Spinal Deformity ◽

Short Form ◽

Adult Spinal Deformity ◽

Physical Component Score ◽

Health State ◽

Scoliosis Research Society ◽

Component Score ◽

Sf 36 ◽

Integrated Health

Abstract BACKGROUND Prior studies have observed similar health-related quality of life (HRQL) in revisions and nonrevision (NR) patients following adult spinal deformity (ASD) correction. However, a novel comparison approach may allow better comparisons in spine outcomes groups. OBJECTIVE To determine if ASD revisions for radiographic and implant-related complications undergo a different recovery than NR patients. METHODS Inclusion: ASD patients with complete HRQL (Oswestry Disability Index, Short-Form-36 version 2 (SF-36), Scoliosis Research Society [SRS]-22) at baseline, 6 wk, 1 yr, 2 yr. Generated revision groups: nonrevision (NR), revised-complete data (RC; with follow-up 2 yr after revision), and revised-incomplete data (RI; without 2-yr follow-up after revision). In a traditional analysis, analysis of variance (ANOVA) compared baseline HRQLs to follow-up changes. In a novel approach, integrated health state was normalized at baseline using area under curve analysis before ANOVA t-tests compared follow-up statuses. RESULTS Two hundred fifty-eight patients were included with 50 undergoing reoperations (19.4%). Rod fractures (n = 15) and proximal joint kyphosis (n = 9) were most common. In standard HRQL analysis, comparing RC index surgery and RC revision surgery HRQLS revealed no significant differences throughout the 2-yr follow-up from either the initial index or revision procedure. Using normalized HRQL/integrated health state, RI displayed worse scores in SF-36 Physical Component Score, SRS activity, and SRS appearance relative to NR (P < .05), indicating less improvement over the 2-yr period. RC were significantly worse than RI in SF-36 Mental Component Score, SRS mental, SRS satisfaction, and SRS total (P < .05). CONCLUSION ASD patients indicated for revisions for radiographic and implant-related complications differ significantly in their overall 2-yr recovery compared to NR, using a normalized integrated health state method. Traditional methods for analyzing revision patients' recovery kinetics may overlook delayed improvements.

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Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity

Neurosurgery ◽

10.1227/neu.0000000000001116 ◽

2016 ◽

Vol 78 (6) ◽

pp. 851-861 ◽

Cited By ~ 92

Author(s):

◽

Justin S. Smith ◽

Virginie Lafage ◽

Christopher I. Shaffrey ◽

Frank Schwab ◽

...

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Short Form ◽

Adult Spinal Deformity ◽

Research Society ◽

Nonoperative Treatment ◽

Leg Pain ◽

Scoliosis Research Society

Abstract BACKGROUND: High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed. OBJECTIVE: To compare outcomes of operative and nonoperative treatment for ASD. METHODS: This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence–to–lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up. RESULTS: Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence–to–lumbar lordosis mismatch, and sagittal vertical axis (P ⩽ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications. CONCLUSION: Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability.

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Is the Cranial Sagittal Vertical Axis (Cr-SVA) a Better Midterm Predictor of Clinical Results Than C7-SVA in Adult Patients Operated on Spinal Deformity After a Minimum 2-Year Follow-Up?

Clinical Spine Surgery ◽

10.1097/bsd.0000000000001034 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Alejandro Gomez-Rice ◽

Cristina Madrid ◽

Enrique Izquierdo ◽

Fernando Marco-Martínez ◽

Jesús A.F. Tresguerres ◽

...

Keyword(s):

Spinal Deformity ◽

Vertical Axis ◽

Clinical Results ◽

Adult Patients ◽

Sagittal Vertical Axis

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Reduced occurrence of primary rod fracture after adult spinal deformity surgery with accessory supplemental rods: retrospective analysis of 114 patients with minimum 2-year follow-up

Journal of Neurosurgery Spine ◽

10.3171/2020.12.spine201527 ◽

2021 ◽

pp. 1-12

Author(s):

Emily P. Rabinovich ◽

Thomas J. Buell ◽

Tony R. Wang ◽

Christopher I. Shaffrey ◽

Justin S. Smith

Keyword(s):

Retrospective Analysis ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Vertical Axis ◽

Transforaminal Lumbar Interbody Fusion ◽

Inclusion Criteria ◽

Sagittal Vertical Axis ◽

Rod Fracture

OBJECTIVE Rod fracture (RF) after adult spinal deformity (ASD) surgery is reported in approximately 6.8%–33% of patients and is associated with loss of deformity correction and higher reoperation rates. The authors’ objective was to determine the effect of accessory supplemental rod (ASR) placement on postoperative occurrence of primary RF after ASD surgery. METHODS This retrospective analysis examined patients who underwent ASD surgery between 2014 and 2017 by the senior authors. Inclusion criteria were age > 18 years, ≥ 5 instrumented levels including sacropelvic fixation, and diagnosis of ASD, which was defined as the presence of pelvic tilt ≥ 25°, sagittal vertical axis ≥ 5 cm, thoracic kyphosis ≥ 60°, coronal Cobb angle ≥ 20°, or pelvic incidence to lumbar lordosis mismatch ≥ 10°. The primary focus was patients with a minimum 2-year follow-up. RESULTS Of 148 patients who otherwise met the inclusion criteria, 114 (77.0%) achieved minimum 2-year follow-up and were included (68.4% were women, mean age 67.9 years, average body mass index 30.4 kg/m2). Sixty-two (54.4%) patients were treated with traditional dual-rod construct (DRC), and 52 (45.6%) were treated with ASR. Overall, the mean number of levels fused was 11.7, 79.8% of patients underwent Smith-Petersen osteotomy (SPO), 19.3% underwent pedicle subtraction osteotomy (PSO), and 66.7% underwent transforaminal lumbar interbody fusion (TLIF). Significantly more patients in the DRC cohort underwent SPO (88.7% of the DRC cohort vs 69.2% of the ASR cohort, p = 0.010) and TLIF (77.4% of the DRC cohort vs 53.8% of the ASR cohort, p = 0.0001). Patients treated with ASR had greater baseline sagittal malalignment (12.0 vs 8.6 cm, p = 0.014) than patients treated with DRC, and more patients in the ASR cohort underwent PSO (40.3% vs 1.6%, p < 0.0001). Among the 114 patients who completed follow-up, postoperative occurrence of RF was reported in 16 (14.0%) patients, with mean ± SD time to RF of 27.5 ± 11.8 months. There was significantly greater occurrence of RF among patients who underwent DRC compared with those who underwent ASR (21.0% vs 5.8%, p = 0.012) at comparable mean follow-up (38.4 vs 34.9 months, p = 0.072). Multivariate analysis demonstrated that ASR had a significant protective effect against RF (OR 0.231, 95% CI 0.051–0.770, p = 0.029). CONCLUSIONS This study demonstrated a statistically significant decrease in the occurrence of RF among ASD patients treated with ASR, despite greater baseline deformity and higher rate of PSO. These findings suggest that ASR placement may provide benefit to patients who undergo ASD surgery.

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Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets

Journal of Neurosurgery Spine ◽

10.3171/2021.3.spine202140 ◽

2021 ◽

pp. 1-9

Author(s):

Ferran Pellisé ◽

Miquel Serra-Burriel ◽

Alba Vila-Casademunt ◽

Jeffrey L. Gum ◽

Ibrahim Obeid ◽

...

Keyword(s):

Quality Of Life ◽

Spinal Deformity ◽

Oswestry Disability Index ◽

Adult Spinal Deformity ◽

Research Society ◽

Data Sets ◽

Scoliosis Research Society ◽

Sagittal Deformity

OBJECTIVE The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010. METHODS This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR). RESULTS Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010–2011 vs 2015–2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence–lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01). CONCLUSIONS The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

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Orthopedic disease burden in adult patients with symptomatic lumbar scoliosis: results from a prospective multicenter study

Journal of Neurosurgery Spine ◽

10.3171/2021.1.spine201911 ◽

2021 ◽

pp. 1-9

Author(s):

Justin S. Smith ◽

Christopher I. Shaffrey ◽

Christine R. Baldus ◽

Michael P. Kelly ◽

Elizabeth L. Yanik ◽

...

Keyword(s):

Surgical Treatment ◽

Multicenter Study ◽

Disease Burden ◽

Health Impact ◽

Research Society ◽

Leg Pain ◽

Prospective Multicenter Study ◽

Scoliosis Research Society ◽

Lumbar Scoliosis

OBJECTIVE Although the health impact of adult symptomatic lumbar scoliosis (ASLS) is substantial, these patients often have other orthopedic problems that have not been previously quantified. The objective of this study was to assess disease burden of other orthopedic conditions in patients with ASLS based on a retrospective review of a prospective multicenter cohort. METHODS The ASLS-1 study is an NIH-sponsored prospective multicenter study designed to assess operative versus nonoperative treatment for ASLS. Patients were 40–80 years old with ASLS, defined as a lumbar coronal Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20, or Scoliosis Research Society-22 questionnaire score ≤ 4.0 in pain, function, and/or self-image domains. Nonthoracolumbar orthopedic events, defined as fractures and other orthopedic conditions receiving surgical treatment, were assessed from enrollment to the 4-year follow-up. RESULTS Two hundred eighty-six patients (mean age 60.3 years, 90% women) were enrolled, with 173 operative and 113 nonoperative patients, and 81% with 4-year follow-up data. At a mean (± SD) follow-up of 3.8 ± 0.9 years, 104 nonthoracolumbar orthopedic events were reported, affecting 69 patients (24.1%). The most common events were arthroplasty (n = 38), fracture (n = 25), joint ligament/cartilage repair (n = 13), and cervical decompression/fusion (n = 7). Based on the final adjusted model, patients with a nonthoracolumbar orthopedic event were older (HR 1.44 per decade, 95% CI 1.07–1.94), more likely to have a history of tobacco use (HR 1.63, 95% CI 1.00–2.66), and had worse baseline leg pain scores (HR 1.10, 95% CI 1.01–1.19). CONCLUSIONS Patients with ASLS have high orthopedic disease burden, with almost 25% having a fracture or nonthoracolumbar orthopedic condition requiring surgical treatment during the mean 3.8 years following enrollment. Comparisons with previous studies suggest that the rate of total knee arthroplasty was considerably greater and the rates of total hip arthroplasty were at least as high in the ASLS-1 cohort compared with the similarly aged general US population. These conditions may further impact health-related quality of life and outcomes assessments of both nonoperative and operative treatment approaches in patients with ASLS.

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Association between bicortical screw fixation at upper instrumented vertebra and risk for upper instrumented vertebra fracture

Journal of Neurosurgery Spine ◽

10.3171/2016.10.spine16535 ◽

2017 ◽

Vol 26 (5) ◽

pp. 638-644 ◽

Cited By ~ 5

Author(s):

Young-Seop Park ◽

Seung-Jae Hyun ◽

Ho Yong Choi ◽

Ki-Jeong Kim ◽

Tae-Ahn Jahng

Keyword(s):

Spinal Deformity ◽

Pelvic Incidence ◽

Screw Fixation ◽

Adult Spinal Deformity ◽

Vertical Axis ◽

Sagittal Vertical Axis ◽

The Mean ◽

Upper Instrumented Vertebra ◽

Bicortical Screw

OBJECTIVEThe aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery.METHODSA single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9–L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV.RESULTSThe mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence–LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02).CONCLUSIONSBicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.

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Αποτελεσματικότητα και επίδραση στην ποιότητα ζωής του τροποποιημένου κηδεμόνα τύπου Boston στην ιδιοπαθή εφηβική σκολίωση

10.12681/eadd/39468 ◽

2016 ◽

Author(s):

Σταύρος Πέλλιος

Keyword(s):

Odds Ratio ◽

Oswestry Disability Index ◽

Short Form ◽

Research Society ◽

Short Form 36 ◽

Scoliosis Research Society

Η ιδιοπαθής εφηβική σκολίωση αποτελεί μια τρισδιάστατη παραμόρφωση της σπονδυλικής στήλης που εμφανίζεται στον αναπτυσσόμενο σκελετό.Χαρακτηρίζεται από μεγάλη ποικιλομορφία ανάμεσα στον παιδικό πληθυσμό και ένα μικρό ποσοστό των σκολιωτικών κυρτωμάτων που παρουσιάζουν προοδευτική επιδείνωση απαιτούν θεραπευτική αντιμετώπιση.Οι σκληροί θωρακοοσφυϊκοί κηδεμόνες αποτελούν το κύριο θεραπευτικό μέσο της συντηρητικής αντιμετώπισης της ιδιοπαθούς εφηβικής σκολίωσης.Η χρήση του κηδεμόνα συγκριτικά με την απλή παρατήρηση προσφέρει περισσότερο στην αντιμετώπιση των επιδεινούμενων σκολιωτικών κυρτωμάτων και η απόδοση της θεραπευτικής τους δράσης σχετίζεται με τον αυξημένο χρόνο ημερήσιας εφαρμογής.Η συμμόρφωση και η αποδοχή ωστόσο παραμένει η κυριότερη δυσκολία στην επιλογή αυτής της θεραπευτικής μεθόδου.Τα σκολιωτικά κυρτώματα δε σταματούν απαραίτητα να εξελίσσονται μετά το πέρας της εφαρμογής του κηδεμόνα καθώς επίσης και μετά την ολοκλήρωση της σκελετικής ανάπτυξης.Η γνώση των επιβαρυντικών παραγόντων που επιδρούν στη συμπεριφορά του κυρτώματος μετά την αφαίρεση του κηδεμόνα είναι κρίσιμο για την πρόγνωση των ασθενών με ιδιοπαθή εφηβική σκολίωση.Η δυσκολία στην ολοκλήρωση τυχαιοποιημένων κλινικών μελετών καθιστούν τις μελέτες κοόρτης το κύριο μέσο συλλογής πληροφοριών για την εξέλιξη της σκολίωσης.Ο σκοπός της δικής μας μελέτης ήταν να παρουσιάσουμε αποτελέσματα ασθενών με ιδιοπαθή εφηβική σκολίωση,μετά από 25 χρόνια παρακολούθησης,που εφάρμοσαν τον τροποποιημένο κηδεμόνα Boston για 3 χρόνια και διαχωρίστηκαν σε 2 ομάδες ανάλογα με τον ημερήσιο χρόνο εφαρμογής του κηδεμόνα(18 και 23 ώρες).Στόχος μας ήταν: α) να προσδιορίσουμε την απώλεια της διόρθωσης που προσέφερε ο κηδεμόνας 25 χρόνια μετά την αφαίρεσή του β) να συγκρίνουμε τις δύο ομάδες που έφεραν τον κηδεμόνα 18 και 23 ώρες ημερησίως γ) να προσδιορίσουμε τους προγνωστικούς παράγοντες που επιδρούν στην απώλεια της διόρθωσης μετά την αφαίρεση του κηδεμόνα.Σε σύνολο 117 ασθενών,επανεκτιμήθηκαν σύμφωνα με το ερευνητικό πρωτόκολλο 77 ασθενείς.Η καταγραφή στοιχείων αφορούσε το κύριο σκολιωτικό τους κύρτωμα όπως το μέγεθος,το είδος,η στροφή του κορυφαίου σπονδύλου πριν,κατά τη διάρκεια,αμέσως μετά την εφαρμογή του κηδεμόνα και 25 χρόνια μετά.Έγινε καταγραφή σωματομετρικών και δημογραφικών στοιχείων και εκτίμηση της ποιότητας ζωής με τη συμπλήρωση των Short-Form 36,Oswestry Disability Index και Scoliosis Research Society-22 ερωτηματολογίων.Μετά την ανάλυση των στοιχείων που καταγράψαμε καταλήξαμε στα εξής αποτελέσματα:Η μέση ηλικία των ασθενών ήταν 40.4(±3.2) έτη.Επανεκτιμήθηκαν 25.16(±2.69) χρόνια μετά την αφαίρεση του κηδεμόνα και το σκολιωτικό κύρτωμα ενώ είχε ελαττωθεί κατά μέσο όρο 6.65⁰(±9.5) αμέσως μετά την αφαίρεση,στην μακροχρόνια επανεκτίμηση αυξήθηκε κατά μέσο 3.9⁰(±6.69)Δεν υπήρξε όμως καμία στατιστικώς σημαντική διαφορά στη μέση τιμή της γωνίας Cobb του σκολιωτικού κυρτώματος πριν την εφαρμογή του κηδεμόνα και 25 χρόνια μετά την αφαίρεση του.(p=0.307).Οι δύο ομάδες που διαχωρίστηκαν με βάση τον ημερήσιο χρόνο εφαρμογής του κηδεμόνα (18 και 23 ώρες) συγκρίθηκαν σε δημογραφικά,σωματομετρικά στοιχεία,σε παραμέτρους που αφορούν το σκολιωτικό κύρτωμα και τη χρήση του κηδεμόνα.Ήταν στατιστικά συγκρίσιμες οι δύο ομάδες(35 και 42 ασθενείς) σε όλες τις παραμέτρους και δε βρέθηκε καμία σημαντική διαφορά στο μέγεθος του σκολιωτικού κυρτώματος μεταξύ των δύο ομάδων τόσο τη χρονική στιγμή της αφαίρεσης(p=0.512) όσο και 25 χρόνια μετά(p=0.878).Επίσης δεν υπήρξε κάποια στατιστικά σημαντική διαφορά στην ποιότητα ζωής των ασθενών των δύο ομάδων με βάση την αξιολόγηση των ερωτηματολογίων.Στην ανάλυση των παραγόντων που επιδρούν στην απώλεια της διόρθωσης μετά την αφαίρεση του κηδεμόνα καταλήξαμε σ’ένα προγνωστικό μοντέλο που περιλαμβάνει το μέγεθος του κύριου σκολιωτικού κυρτώματος και τη στροφή του κορυφαίου σπονδύλου που εξηγεί κατά 65%(R square=0,650 ,p=0,000) τη διαφορά στην απώλεια της διόρθωσης που λαμβάνει χώρα μετά την αφαίρεση του κηδεμόνα.Σκολιωτικό κύρτωμα με στροφή του κορυφαίου σπονδύλου μεγαλύτερη των 20⁰ μετά την αφαίρεση του κηδεμόνα έχει 3 φορές μεγαλύτερη πιθανότητα να επιδεινωθεί σε σχέση με αντίστοιχο που ο κορυφαίος σπόνδυλος έχει μικρότερη στροφή(Odds ratio 3.071,CI:0.992-9.514)Συμπερασματικά,εκτιμώντας τα μακροχρόνια αποτελέσματα της ιδιοπαθούς εφηβικής σκολίωσης και της αντιμετώπισης της δεν είναι αναγκαίο να εφαρμόζεται ο κηδεμόνας περισσότερο από 18 ώρες ημερησίως και μπορεί να αποφεύγεται η χρήση του κατά τη διάρκεια του σχολείου.Όπως επίσης και η στροφή του κορυφαίου σπονδύλου κατά την αφαίρεση του κηδεμόνα αποτελεί ισχυρό παράγοντα κινδύνου επιδείνωσης του σκολιωτικού κυρτώματος και απώλειας της όποιας διόρθωσης.

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Patients with High Pelvic Tilt Achieve the Same Clinical Success as Those with Low Pelvic Tilt After Minimally Invasive Adult Deformity Surgery

Neurosurgery ◽

10.1093/neuros/nyx383 ◽

2017 ◽

Vol 83 (2) ◽

pp. 270-276 ◽

Cited By ~ 2

Author(s):

Juan S Uribe ◽

Jacob Januszewski ◽

Michael Wang ◽

Neel Anand ◽

David O Okonkwo ◽

...

Keyword(s):

Minimally Invasive ◽

Spinal Deformity ◽

Pelvic Tilt ◽

Adult Spinal Deformity ◽

Vertical Axis ◽

Sagittal Vertical Axis ◽

Adult Deformity ◽

Radiographic Outcomes ◽

Hrqol Data

Abstract BACKGROUND Pelvic tilt (PT) is a compensatory mechanism for adult spinal deformity patients to mitigate sagittal imbalance. The association between preop PT and postop clinical and radiographic outcomes has not been well studied in patients undergoing minimally invasive adult deformity surgery. OBJECTIVE To evaluate clinical and radiographic outcomes in adult spinal deformity patients with high and low preoperative PT treated surgically using less invasive techniques. METHODS Retrospective case-control, institutional review board-approved study. A multicenter, minimally invasive surgery spinal deformity patient database was queried for 2-yr follow-up with complete radiographic and health-related quality of life (HRQOL) data. Hybrid surgery patients were excluded. Inclusion criteria were as follows: age > 18 and either coronal Cobb angle > 20, sagittal vertical axis > 5 cm, pelvic incidence-lumbar lordosis (PI-LL) > 10 or PT > 20. Patients were stratified by preop PT as per Schwab classification: low (PT< 20), mid (PT 20-30), or high (>30). Postoperative radiographic alignment parameters (PT, PI, LL, Cobb angle, sagittal vertical axis) and HRQOL data (Visual Analog Scale Back/Leg, Oswestry Disability Index) were evaluated and analyzed. RESULTS One hundred sixty-five patients had complete 2-yr outcomes data, and 64 patients met inclusion criteria (25 low, 21 mid, 18 high PT). High PT group had higher preop PI-LL mismatch (32.1 vs 4.7; P < .001). At last follow-up, 76.5% of patients in the high PT group had continued PI-LL mismatch compared to 34.8% in the low PT group (P < .006). There was a difference between groups in terms of postop changes of PT (–3.9 vs 1.9), LL (8.7 vs 0.5), and PI-LL (–9.5 vs 0.1). Postoperatively, HRQOL data (Oswestry Disability Index and Visual Analog Scale) were significantly improved in both groups (P < .001). CONCLUSION Adult deformity patients with high preoperative PT treated with minimally invasive surgical techniques had less radiographic success but equivalent clinical outcomes as patients with low PT.

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