Complications of Surgical Treatment of Adult Scoliosis

Introduction: With the increase in global life expectancy, the number of patients presenting with progressive spinal deformities is also on rise. The increasing frequency of surgical intervention as a treatment of this group of patients is associated with many complications and also with increasing rate of reoperation. Methodology: Seventy-two cases of adult scoliosis were treated surgically in Ain Shams spine unit with a minimum follow-up of five years (average, 76 months). Preoperative clinical and radiological evaluation was done, with special emphasis on the degree of pains (back and leg), Oswestry Disability Index (ODI), scoliosis angle, lumbar lordosis, any instability, and the level of spinal canal stenosis needing decompression. The pelvic incidence was measured preoperatively to plan the amount of lordosis needed to be restored. Result: The mean preoperative scoliosis angle was 22 ± 10.4º (16 to 34º) and the mean preoperative lordosis angle was 20.3 ± 12.7º (–15 to –28º). The mean preoperative ODI score was 54.7 ± 5.5, and the mean postoperative scoliosis angle improved to 7.4 ± 3.3. The mean postoperative lordosis angle became 37.3 ± 8.6, and the mean postoperative ODI score was 21.3 ± 3.8. Conclusion: The list of complications included seven cases of pseudoarthrosis and screw loosening, adjacent segment fracture in nine cases, and one case of spondylodiscitis at a level just proximal to the fused level. These 17 cases needed reoperations (24%). Additionally, there were five cases of dural tear, prolonged graft side pain in one case, and two cases of superficial wound infections.

Evaluating measures of quality of life in adult scoliosis: a protocol for a systematic review and narrative synthesis

Background Adult scoliosis represents a distinct subgroup of scoliosis patients for whom the diagnosis can have a large impact on their health-related quality of life (HR-QOL). Therefore, HR-QOL patient-reported outcome measures (PROMs) are essential to assess disease progression and the impact of interventions. The objective of this systematic review is to evaluate the measurement properties of HR-QOL PROMs in adult scoliosis patients. Methods We will conduct a literature search, from their inception onwards, of multiple electronic databases including AMED, CINAHL, EMBASE, Medline, PsychINFO and PubMed. The searches will be performed in two stages. For both stages of the search, participants will be aged 18 and over with a diagnosis of scoliosis. The primary outcome of interest in the stage one searches will be studies which use PROMs to investigate HR-QOL as defined by the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy, the secondary outcome will be to assess the frequency of use of the various PROMs. In stage two, the primary outcome of interest will be studies which assess the measurement properties of the HR-QOL PROMs identified in stage one. No specific measurement property will be given priority. No planned secondary outcomes have been identified but will be reported if discovered. In stage one, the only restriction on study design will be the exclusion of systematic reviews. In Stage two the only restriction on study design will be the exclusion of full-text articles not available in the English language. Two reviewers will independently screen all citations and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or risk of bias) will be appraised using the Consensus-based Standards for the selection of Health Measurement Instruments (COSMIN) checklist. The overall strength of the body of evidence will then be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A narrative synthesis will be provided with information presented in the main text and tables to summarise and explain the characteristics and findings of the included studies. The narrative synthesis will explore the evidence for currently used PROMs in adult scoliosis patients and any areas that require further study. Discussion The review will help clinicians and researchers identify a HR-QOL PROM for use in patients with adult scoliosis. Findings from the review will be published and disseminated through a peer-reviewed journal and conference presentations. Systematic review registration This systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), reference number: CRD42020219437

Lateral Thoracolumbar Listhesis as an Independent Predictor of Disability in Adult Scoliosis Patients: Multivariable Assessment Before and After Surgical Realignment

BACKGROUND Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. OBJECTIVE To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. METHODS This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20º) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. RESULTS In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (<6.7%), moderate (6.7-15.4%), and severe (≥15.4%). In multivariable analysis, listhesis of moderate and severe vs none/mild was associated with worse baseline ODI (none/mild = 33.7; moderate = 41.6; severe = 43.9; P < .001 for both comparisons) and leg pain NSR (none/mild = 2.9, moderate = 4.0, severe = 5.1, P < .05). Resolution of severe lateral listhesis to none/mild was independently associated with increased likelihood of reaching MCID in ODI at 2 yr postoperatively (odds ratio 2.1 95% confidence interval 1.2–3.7, P = .0097). CONCLUSION Lateral thoracolumbar listhesis is associated with worse baseline disability among adult scoliosis patients. Resolution of severe lateral listhesis following deformity correction was independently associated with increased likelihood of reaching MCID in ODI at 2-yr follow-up.

Cervical Spinal Cord Compression in Adult Scoliosis

Study Design Retrospective cohort study. Objectives The aim was to examine cervical spinal cord compression (SCC) in adult scoliosis and clarify the prevalence of and risk factors for cervical SCC. Methods This study included 270 adult scoliosis patients and 1211 healthy volunteers. Cervical SCC was evaluated on cervical magnetic resonance imaging (MRI). The rates of SCC for those with adult scoliosis and the healthy volunteers were compared. Logistic regression analysis was conducted to examine the factors associated with cervical SCC on MRI. Results In cases with adult scoliosis, preoperative major scoliosis curve was 56.0° ± 18.8°, and cervical SCC was detected in 25 patients (9.3%). Among the healthy volunteers, 64 cases with cervical SCC were detected. Only in cases with adult scoliosis, logistic regression analysis revealed higher age (OR 1.09, 95% CI 1.04–1.14, P < .001), narrow canal diameter (OR 2.27, 95% CI 1.35–3.85, P = .002), and inferior sagittal balance (OR 2.45, 95% CI 1.02–5.89, P = .04) as significant risk factors. In the logistic regression analysis in all subjects (including adult scoliosis and healthy volunteers), higher age (OR 1.08, 95% CI 1.06–1.10, P < .001) and narrow canal diameter (OR 1.62, 95% CI 1.37–1.92, P < .001) were also found to be significant risk factors, but the presence of scoliosis was not a significant factor. Conclusions Adult scoliosis itself was not significantly associated with cervical SCC. Inferior sagittal balance in addition to scoliosis constituted a significant risk factor for cervical SCC.

Patient outcomes after circumferential minimally invasive surgery compared with those of open correction for adult spinal deformity: initial analysis of prospectively collected data

OBJECTIVE Circumferential minimally invasive spine surgery (cMIS) for adult scoliosis has become more advanced and powerful, but direct comparison with traditional open correction using prospectively collected data is limited. The authors performed a retrospective review of prospectively collected, multicenter adult spinal deformity data. The authors directly compared cMIS for adult scoliosis with open correction in propensity-matched cohorts using health-related quality-of-life (HRQOL) measures and surgical parameters. METHODS Data from a prospective, multicenter adult spinal deformity database were retrospectively reviewed. Inclusion criteria were age > 18 years, minimum 1-year follow-up, and one of the following characteristics: pelvic tilt (PT) > 25°, pelvic incidence minus lumbar lordosis (PI-LL) > 10°, Cobb angle > 20°, or sagittal vertical axis (SVA) > 5 cm. Patients were categorized as undergoing cMIS (percutaneous screws with minimally invasive anterior interbody fusion) or open correction (traditional open deformity correction). Propensity matching was used to create two equal groups and to control for age, BMI, preoperative PI-LL, pelvic incidence (PI), T1 pelvic angle (T1PA), SVA, PT, and number of posterior levels fused. RESULTS A total of 154 patients (77 underwent open procedures and 77 underwent cMIS) were included after matching for age, BMI, PI-LL (mean 15° vs 17°, respectively), PI (54° vs 54°), T1PA (21° vs 22°), and mean number of levels fused (6.3 vs 6). Patients who underwent three-column osteotomy were excluded. Follow-up was 1 year for all patients. Postoperative Oswestry Disability Index (ODI) (p = 0.50), Scoliosis Research Society–total (p = 0.45), and EQ-5D (p = 0.33) scores were not different between cMIS and open patients. Maximum Cobb angles were similar for open and cMIS patients at baseline (25.9° vs 26.3°, p = 0.85) and at 1 year postoperation (15.0° vs 17.5°, p = 0.17). In total, 58.3% of open patients and 64.4% of cMIS patients (p = 0.31) reached the minimal clinically important difference (MCID) in ODI at 1 year. At 1 year, no differences were observed in terms of PI-LL (p = 0.71), SVA (p = 0.46), PT (p = 0.9), or Cobb angle (p = 0.20). Open patients had greater estimated blood loss compared with cMIS patients (1.36 L vs 0.524 L, p < 0.05) and fewer levels of interbody fusion (1.87 vs 3.46, p < 0.05), but shorter operative times (356 minutes vs 452 minutes, p = 0.003). Revision surgery rates between the two cohorts were similar (p = 0.97). CONCLUSIONS When cMIS was compared with open adult scoliosis correction with propensity matching, HRQOL improvement, spinopelvic parameters, revision surgery rates, and proportions of patients who reached MCID were similar between cohorts. However, well-selected cMIS patients had less blood loss, comparable results, and longer operative times in comparison with open patients.