Directed Versus Nondirected Standing Postures in Adolescent Idiopathic Scoliosis: Its Impact on Curve Magnitude, Alignment, and Clinical Decision-Making.

STUDY DESIGN: Prospective study. OBJECTIVE: To investigate the difference in major curve Cobb angle and alignment between directed and nondirected positioning for adolescent idiopathic scoliosis (AIS) and to evaluate implications on treatment decision-making. SUMMARY OF BACKGROUND DATA: Proper positioning of patients with spinal deformities is important for assessing usual functional posture in standing, so management strategies can be customized accordingly. Whether postural variability affects coronal and sagittal radiologic parameters and the impact of posture on management decisions remains unknown. PATIENTS AND METHODS: Patients with adolescent idiopathic scoliosis presenting for an initial consultation at a tertiary scoliosis clinic were recruited. They were asked to stand in two positions: passive, nondirected position; and directed position by the radiographer. Radiologic assessment included major and minor Cobb angle, coronal balance, spinopelvic parameters, sagittal balance, and alignment. Cobb angle difference >5° between directed and nondirected positioning was considered clinically impactful. Patients with or without such differences were compared. Overestimation or underestimation of the major curve (at 25° or 40°) by nondirected positioning were examined due to its relevance to bracing and surgical indications. RESULTS: This study included 198 patients, with 22.2% experiencing Cobb angle difference (>5°) between positioning. The major curve Cobb angle was smaller in nondirected than directed positioning (median difference: -6.0°, upper and lower quartile: -7.8, 5.8), especially for curves ≥30°. Patients with a Cobb angle difference had changes in shoulder balance ( P =0.007) when assuming a directed position. Nondirected positioning had 14.3% of major Cobb 25° underestimated and 8.8% overestimated, whereas 11.1% of curves >40° were underestimated. CONCLUSION: Strict adherence to a standardized radiographic protocol is mandatory for reproducing spine radiographs reliable for curve assessment, as a nondirected position demonstrates smaller Cobb angles. Postural variation may lead to overestimation, or underestimation, of the curve size which is relevant to both bracing and surgical decision-making. LEVEL OF EVIDENCE: Level-II.

Predictive factors for successful non-operative treatment and achieving MCID improvement in health-related quality of life in adult spinal deformity.

BACKGROUND: Adult spinal deformity is a spectrum of degenerative spinal diseases with increasing prevalence and healthcare burden worldwide. Identification of patients who are more likely to improve through conservative management may reduce cost and potentially prevent surgery and its associated costs and complications. This study aims to identify predictive factors for MCID in improvement of ODI and SRS-22r questionnaires in patients with adult spinal deformity treated with conservative treatment. METHODS: A prospective, observational cohort study of 46 patients was conducted at a spine specialist clinic. Inclusion criteria were 30-80 years of age, diagnosis of neglected adolescent idiopathic scoliosis, de-novo scoliosis, degenerative spondylolisthesis, and sagittal plane deformities (thoracic hypokyphosis, lumbar hypolordosis), presenting with mechanical back pain with or without radicular leg pain. All patients received conservative management including medication and physiotherapy. Radiological and clinical parameters were measured at baseline and at 1-year follow-up. Primary outcomes were ODI and SRS-22r scores. Secondary outcomes were EQ-5D-5L scores and requiring spine surgery during conservative treatment. Predictors for MCID improvement in ODI and SRS-22r were identified using multivariate regressions and receiver operating characteristic (ROC) analyses. RESULTS: At baseline, patients who reached MCID in ODI and/or SRS-22r showed less comorbidities (diabetes mellitus, hypertension, ischemic heart disease, osteoarthritis, cancer), smaller range of lateral spinal flexion, larger trunk shift, larger pelvic incidence, a higher EQ-5D-5L anxiety/depression dimension score, a lower SRS-22r total score, and presence of spondylolisthesis. Lateral flexion range < 25 degrees, trunk shift > 14 mm, pelvic incidence > 50 degrees, EQ-5D-5L anxiety/depression dimension score > 1, and SRS-22r total score < 3.5 were the cut-off values generated by ROC analysis. CONCLUSIONS: Both radiological and clinical predictive factors for MCID improvement in health-related quality of life were identified. Future research should identify subgroups of patients who are responsive to specific conservative treatment modalities, so as to provide information for personalized medicine. LEVEL OF EVIDENCE: II.